吴仁毅青光眼诊治新进展

青光眼诊治新进展及共识,浙江大学医学院附属第二医院眼科中心吴仁毅,“治愈”青光眼,诊断,治疗,新模式,“治愈”青光眼,诊断,治疗,新模式,早期青光眼性视神经病变 晚期青光眼性视神经病变 前房角关闭的检测 闭角型青光眼的预测 青光眼形态（结构）进展 青光眼视功能进展,早期青光眼性视神经病变 晚期青光眼性视神经病变 前房角关闭的检测 闭角型青光眼的预测 青光眼形态（结构）进展 青光眼视功能进展,诊断,治疗,新模式,药物 手术 药物缓释系统（纳米颗粒） 激光 滤过道瘢痕化控制,“治愈”青光眼,早期青光眼性视神经病变 晚期青光眼性视神经病变 前房角关闭的检测 闭角型青光眼的预测 青光眼形态（结构）进展 青光眼视功能进展,“治愈”青光眼,诊断,治疗,新模式,药物 手术 药物缓释系统（纳米颗粒） 激光 滤过道瘢痕化调控,神经保护 血流 干细胞 基因诊断（危险因素，药物 选择，ACG易感性，等） 基因治疗（前房内注入基因 改造小梁网，等）,OCT 检查的进展,眼前段OCT (光学相干断层扫描）,优点 分辨率高（1020 mm) vs UBM (20-60 mm) 操作简单，易于掌握 非接触，安全性高 无机械操作对组织的干扰缺点 易受屈光间质混浊和高反射的虹膜上皮影响 不能完整显示睫状体及其后区域,眼前段OCT,眼前段OCT,眼前段OCT,眼前段OCT对闭角型青光眼的检测,The Iris Loses Half Its Volume During Pupil Dilation: A New Risk Factor for Angle Closure Glaucoma. H.A. Quigley, et al. ARVO 2008,20 open angle suspects or patients (OAG)19 angle closure suspects or patients (ACG) Visante anterior segment OCT imaging under 3 conditions,maximum pupil constriction to light maximum physiological dilation in darkafter pharmacological dilation,The Iris Loses Half Its Volume During Pupil Dilation: A New Risk Factor for Angle Closure Glaucoma. H.A. Quigley, et al. ARVO 2008,Iris area decreased 10.2 + 2.5% with each mm increase in pupil diameter Dilation = Squeezing a sponge Iris volume change as a predictor of ACG,OCT 检查的进展,复谱频域（Spectral/Fourier Domain) OCT (光学相干断层扫描）,Old vs New,Zeiss Stratus OCT 2002Time domain OCT每秒400次 A 超扫描910 m 轴向分辨率,Optovue/RTvue OCT 2006BioptigenSpectral/Fourier domain OCT每秒26000次 A 超扫描5 m 轴向分辨率,Optovue/RTvue OCT,SD/FD OCT 视盘RNFL分析,SD/FD OCT 视盘RNFL分析,SD/FD OCT 黄斑成像,基于SD/FD OCT 的三维成像,SD/FD OCT 的优势及展望,良好的可重复性 图像更为精细 特异性和敏感性更高 连续和动态在体检查 分析软件需跟进 正常人数据库的建立 可应用于角膜，眼前节，视盘，视网膜等部位,海德堡视网膜断层成像仪 （HRT ）,HRT ,改进 硬件：直接与笔记本电脑相连 软件 扩大数据库样本量 自动评价盘沿是否遵循ISNT原则 青光眼可能性评分 改进了TCA进展分析,角膜,青光眼,黄斑水肿,HRT ,HRT 与OCT在视盘分析上的比较,WGA Consensus Series,Intraocular Pressureedited by: R.N. Weinreb & J.D. Brandt & D. Garway-Heath & F.A. Medeiros,Glaucoma Diagnosis Structure and Functionedited by: R.N. Weinreb & E.L. Greve,Glaucoma Surgery Open Angle Glaucomaedited by: R.N. Weinreb & J.G. Crowston,Angle Closure and Angle Closure Glaucomaedited by: R.N. Weinreb & D.S. Friedman,Consesus Statement on Structural Assessment,A method for detecting abnormality and documenting optic nerve structure should be part of routine clinical management of glaucoma 检测（结构）异常以及记录视盘形态应作为青光眼诊治的常规 According to limited evidence available, SN and SP of imaging devices are comparable to expert interpretation of stereo color photos and should be considered when expert advice is not available 根据目前有限的资料，图像设备的敏感性和特异性与立体彩照的内行解释相当 Digital imaging is recommended as a clinical tool to enhance and facilitate the assessment of the optic disc and RNFL in the management of glaucoma 推荐使用数字化图像技术评价视盘和RNFL,Consesus Statement on Structural Assessment,Automated analysis of results using appropriate data bases is helpful for identifying abnormalities consistent with glaucoma 应用合适的数据库对结果进行自动分析有助于发现青光眼相关的异常Different imaging technologies may be complementary, and detect different abnormal features in the same patients 不同的图像技术可以检测同一病人结构异常的不同特征（方面）,Consesus Statement on Functional Assessmentin the Management of Glaucoma,A method for detecting abnormality and documenting functional status should be part of routine clinical management of glaucoma 检测（功能）异常并记录视功能状态应作为青光眼诊治的常规 Unlikely that one functional test assesses the whole dynamic range of function 一种视功能检查并不能反映整体功能的动态范围,Consesus Statement on Functional Assessmentin the Management of Glaucoma,Standard automated perimetry, as usually employed in clinical practice is not optimal for early detection 临床常用的自动视野检查并非早期青光眼检测的最佳方法 Emerging evidence that SWAP and FDT may accurately detect glaucoma earlier than SAP 相对于SAP，SWAP和FDT可能可以更早检测到青光眼性改变 There is little evidence to support the use of a particular selective visual function test (SWAP VS FDT) over another in clinical practice because there are few studies with adequate comparisons. 没有证据支持选择性的视功能检查 (SWAP 与 FDT) 何者更胜一筹,b阻滞剂与死亡率,Topical b blockers and Mortality:Long-Term and Short Term Effect R. Musken, et al. Presented at ARVO 2008,Purpose: Association between the use of topical timolol and cardiovascular mortality was reported by the Blue Mountains Eye Study (Lee AJ， et al. Ophthalmology 2006). To confirm or falsify this clinically very important finding. Methods: Long-term effects: 3842 participants of the Rotterdam Study were followed from 1997 onwards. Cause of death was registered up to January 1, 2005. Short-term effects: 484 incident beta-blocker users were compared to an age-matched group of 4700 controls. Short term effects (death within three months after the first prescription of topical beta-blockers) were examined using a chi-squared test.,b阻滞剂与死亡率,Topical b blockers and Mortality:Long-Term and Short Term Effect R. Musken, et al. Presented at ARVO 2008,Purpose: Association between the use of topical timolol and cardiovascular mortality was reported by the Blue Mountains Eye Study (Lee et al. Ophthalmology 2006). To confirm or falsify this clinically very important finding. Methods: Long-term effects: 3842 participants of the Rotterdam Study were followed from 1997 onwards. Cause of death was registered up to January 1, 2005. Short-term effects: 484 incident beta-blocker users were compared to an age-matched group of 4700 controls. Short term effects (death within three months after the first prescription of topical beta-blockers) were examined using a chi-squared test.Conclusions: Use of topical beta-blockers appears not to be associated with mortality.,青光眼治疗与眼表异常,Increased Prevalence of Ocular Surface Disease Symptoms in Glaucoma Patients Using IOP-Lowering Medications D.G. Godfrey， et al. Presented at ARVO 2008,Prospective, multi-center, single-visit, survey based study 630 patients using one or more topical IOP-lowering medicationsPrevalence of OSD symptoms:48.4% ODS index , mild, moderate, severeSignificant differences between 1 and 2 ,1 and 3 medications No statistical difference between 2 and 3 medications,固定复方制剂 (Fixed Combinations),Cosopt Dorzolamide/Timolol Combigan Brimonidine/Timolol Xalacom Latanoprost/TimololDuotrav Travoprost/Timolol Ganfort Bimatoprost/Timolol,应用固定复方制剂 的理由,增加患者用药依从性 约50的患者需应用2种或更多滴眼液使眼压降低20 减少洗脱效应 用药间隔5分钟 减少防腐剂相关的副作用,乙酸阿奈可他(Anacortave Acetate, AA),Control of IOP in Open-Angle Glaucoma by Anecortave Acetate: A Comparison of Three Doses and Vehicle. E.R. Craven, et al Presented at ARVO 2008 Anterior Juxtascleral Depot of Anecortave Acetate: Intraocular Pressure Reduction in Different Types of Glaucoma. T.S. Prata, et al. Presented at ARVO 2008,乙酸阿奈可他(Anacortave Acetate, AA),Control of IOP in Open-Angle Glaucoma by Anecortave Acetate: A Comparison of Three Doses and Vehicle. E.R. Craven, et al Presented at ARVO 2008,Randomized double-masked multi-center (N=10) study86 patients , IOP 24-36 mmHgA single 0.5 mL AJD of AA (3, 15, or 30 mg) or vehicle in the “worse” eye. The fellow, non-injected eye was treated with latanoprost.,IOP Success Rate (3 Mon):,30mg =50%, 15 & 3 mg =30%, vehicle= 24%,乙酸阿奈可他(Anacortave Acetate, AA),Anterior Juxtascleral Depot of Anecortave Acetate: Intraocular Pressure Reduction in Different Types of Glaucoma. T.S. Prata, et al. Presented at ARVO 2008,Prospective, non-randomized open-labeled, 25 uncontrolled glaucoma patients. Baseline IOP : 30.9 mmHgA single AJD of AA (30 mg) in the selected eye under topical anesthesia,Mean IOP reduction of 33.3%, 31.7% and 38.3% were observed at the first, second and third month, respectively,Canaloplasty,Canaloplasty,Canaloplasty,术中及术后并发症可能 与学习曲线有关 15（14/94）,前房积血 （3） IOP 30 mmHg (3) 角膜后弹力层撕裂（1） 低眼压 （1） 脉络膜渗漏（1） 缝线暴露 （1）,4例 接受小梁切除术,Trabectome (NeoMedix Inc.),Minckler DS, Baerveldt G, Alfaro MR et al.University of Southern California,Los Angeles, CA, USA.Ophthalmology 2005;112:9627,Trabectome有关的观点,直接去除房水外流的阻碍 术前房角开放 房角解剖标志清晰 需要特定设备 与结膜无关 长期效果？ 有时需联合药物治疗,Consesus on non-penetration surgery and aqueous drainage devices,Non-penetrating surgery is effective in lowering IOP. When compared to antimetabolite trabeculectomy it is safer but in most cases it provides higher final IOPs. Aqueous drainage devices procedures may achieve better IOP control compared to cycloablative procedures in refractory glaucoma.,新生血管性青光眼抗VEGF治疗下一个目标：青光眼？,Avastin (Bevacizumab) 和 Lucentis (Renibizumab) 湿性黄斑变性的有效治疗药物,新生血管性青光眼抗VEGF治疗下一个目标：青光眼？,Avastin (Bevacizumab) 和 Lucentis (Renibizumab) 湿性黄斑变性的有效治疗药物 玻璃体腔内注射可以显著地“消灭”虹膜新生血管 Avastin: 1.25 mg 玻璃体腔注射 IOP 有效控制：8/9 眼 Chalam,KV et al. Eur J Ophthalmol. 2008:18:255-62,Avastin,减少青光眼术后瘢痕形成以及滤过泡血管生成,Kahook MY, et al. Needling bleb revision of encapsulated filitering bleb. Ophthalmic Surg Lasers Imaging. 2006;37:148-150 Kapetansky FM, et al. Subconjunctival injections of bevacizumab for failing fitering blebs. Invest Ophthal Vis Sci. 2007; ARVO, abstract 837,Avastin- 观点,全视网膜光凝（PRP）仍然是新生血管的标准治疗手段 通过视网膜的破坏减少VEGF的生成 临床需要抑制成纤维细胞增殖但不导致结膜极度变薄的药物Avastin: 随时间延长，药效下降 理论上对改善周边视力无效 有创治疗：晶状体损伤，眼内炎，视网膜脱离，视网膜损伤 在晚期或时间较长的新生血管性青光眼中不能有效降低眼内压,青光眼治疗的动物实验,Preservation of Visual Function After Intraocular Transplantation of BDNF Secreting Mesenchymal Stem Cells in Glaucomatous Rat Eyes,D. S. Sakaguchi, et al. ARVO，2007,自体骨髓干细胞（间质干细胞）合成神经营养因子（Neurotrophin）,玻璃体腔内注射（Brown Norway 大鼠）,ERG检查视功能得到保持,神经营养因子治疗的可行性 胚胎干细胞来源：伦理学 免疫学问题,青光眼诊治的共识,原发性青光眼早期诊断的初步建议 1987 年,中国青光眼工作指南（2005） 2005 年,葛坚 中山大学中山眼科中心 青光眼学组组长王宁利北京同仁医院 青光眼学组副组长孙兴怀复旦大学眼耳鼻喉科医院 青光眼学组副组长徐亮 北京市眼科研究所 青光眼学组副组长委员（按姓氏笔画排列）：王大博 青岛大学医学院任泽钦 北京大学人民医院吕建华 河北邢台眼科医院孙乃学 西安交通大学第二医院余敏斌 中山大学中山眼科中心（兼秘书）吴仁毅 浙江大学医学院附属第二医院眼科中心吴玲玲 北京大学附属第三医院眼科中心张虹 华中科技大学同济医院陈晓明 四川大学华西医院眼科中心段宣初 中南大学附属第二医院贺翔鸽 第三军医大学大坪医院赵家良 协和医科大学原慧萍 哈尔滨医科大学附属第二医院徐岩 河南省眼科研究所袁志兰 南京医科大学附属江苏省人民医院袁援生 昆明医学院附属第一医院傅培 北京大学深圳医院潘英姿 北京大学附属第一医院,青光眼学组（Chinese Glaucoma Society),一关于青光眼的基本检查和诊断方法,1眼压检查：在现有的各种眼压计测量方法的基础上，建议使用Goldmann压平眼压计进行眼压测量。诊断正常眼压性青光眼时建议测量昼夜24小时眼压曲线（24小时内至少进行6次检查）。眼压异常时应除外影响眼压的其它因素。,2眼底检查：在使用直接检眼镜检查的基础上，建议采用裂隙灯前置镜检查法、眼底图像记录技术进行眼底检查，以观察并记录眼底变化。青光眼眼底检查应重点观察并记录视乳头盘沿、视网膜神经纤维层和杯盘比改变。杯盘比统一用数字表示，如0.3，0.4，0.5，0. 6；应记录垂直和水平两个方向的杯本身及盘沿的宽度，如垂直径=上盘沿、杯竖径、下盘沿；横径=颞盘沿、杯横径、鼻盘沿，重点记录垂直径下的杯盘比，测量杯的大小按轮廓，不按颜色，即以小血管离开视乳头表面向下弯曲之处作为杯的起始处。,3视野检查：在现有各种视野检查方法的基础上，建议使用国际标准的计算机自动阈值视野计进行视野检查，在视野结果分析时应注意视野检查结果的一致性和可靠性。,4 前房角镜检查：先做静态观察，在不改变前房角解剖状态的条件下区分房角宽窄，并采用Scheie分类法进行分级。然后做动态观察，确定房角开、闭和周边前粘连的程度及范围。房角记录时应进行文字和画图描述，按时钟方位对房角全周的宽度，开、闭、缩短及周边前粘连的宽度和高度做正像文字和画图描述，记录虹膜周边部的形态（凸或凹），记录小梁网色素分级，同时应记录检查时的眼压及用药情况。,二、关于原发性开角型青光眼的诊断,1原发性开角型青光眼高眼压型定义：病理性高眼压（一般认为，超过21mmHg，Goldmann 压平眼压计），眼底有青光眼的特异性损害（视网膜神经纤维层缺损或视乳头改变）和/或视野出现青光眼性损害,房角开放,并排除其它眼压升高的因素，始能确诊为原发性开角型青光眼。,2正常眼压性青光眼归类于原发性开角型青光眼：眼压峰值不超过正常值上限（眼压小于21mmHg，Goldmann 压平眼压计），眼底有青光眼的特征性损害（视网膜神经纤维层缺损或视乳头改变）和/或视野出现青光眼性损害,房角开放,但有上述眼底及视野变化，并排除其它疾病引起的眼底及视野变化，可诊断为正常