白内障幻灯片.ppt

打一疾病,不红不痛渐昏朦，薄雾轻烟渐渐浓。初时一眼先昏暗，数日逐渐障双瞳。千金难买药见效，金针一拨当日空。,cataract,胜利医院林雪媛,教学目的,了解白内障的发生原因及其分型。掌握老年性白内障各型的特点。掌握白内障的手术适应症及白内障术后矫正视力的方法。了解先天性白内障和代谢性白内障的分型及特点。了解晶状体脱位的分型及临床表现。,Whatiscataract?,Acataractisanopacity(orcloudychanges)ofthelensthatcancausevisionproblems.任何先天性或后天性因素引起的晶状体混浊使其透明性下降，称为白内障。,LENS,Thelensissurroundedbyathicklenscapsulewhichisthebasementmembranaeofthelensepithelialcells.晶状体囊是一层包绕整个晶状体的透明囊状基底膜。Epithelialcellsatthelensequatorcontinuetobeproducedthroughoutlife,sothatolderlensfibersarecompressedintoacentralnucleus;youngerfibersaroundthenucleusmakeupthecortex.位于晶状体赤道部囊下的上皮细胞终生增殖，不断形成晶状体纤维，将旧的纤维挤向中心的核，核外较新较疏松的纤维构成皮质。,causes,AgingmostcommonLong-termultraviolet(UV)light,especiallyfromsunlightDiabetesorothersystemicdiseasePasteyeinfections,injuriesorsurgerySmokingLong-termuseofcertainmedications(suchassteroids)heredity,Pathogenesis,Thelensismademostlyofwaterandprotein.Theproteinisarrangedtoletlightpassthroughandfocusontheretina.Sometimessomeoftheproteinclumpstogether.Thiscanstarttocloudsmallareasofthelens,blockingsomelightfromreachingtheretinaandinterferingwithvision.晶状体主要由水和蛋白组成。发生白内障的晶状体特征性改变是蛋白之间的交联形成聚合物，使光线散射增强，晶状体透明度下降。,自由基引起的氧化损伤晶状体上皮细胞氧化损伤膜蛋白降解细胞膜通透性增加晶状体内渗透压增高、肿胀；晶体蛋白之间二硫键形成增多蛋白交联形成高分子量聚合物光散射增强，晶状体混浊。细胞凋亡及其调控,normalVs.cloudylens,ClinicalFindings,SymptomsBlurringordimnessofvision视力下降colorsappearfaded色觉改变Sensitivitytolightandglare眩光Doubleormultiplevision复视或多视Changeinrefraction屈光改变,EyeExam,VisionacuitytestSlitlampOphthalmoscopeInmostcases,eyedropsareusedtodilate(widen)pupilsbeforetheexam.Tonometry,Slitlamp,classification,判断晶状体混浊范围和程度将瞳孔充分散大，采用裂隙灯和后照法，区别晶状体混浊的类型核性（N）、皮质性（C）、后囊下（P）、核的颜色（NC）晶状体核硬度分级标准（据NC）度：透明，无核，软性；度：核呈黄白色或黄色，软核；度：核呈深黄色，中等硬度核；度：核呈棕色或琥珀色，硬核；度：核呈棕褐色或黑色，极硬核。,Age-relatedcataract,年龄相关性白内障是最为常见的白内障类型，多见于50岁以上的中、老年人，随年龄增加其发病率升高。,Therearethreemajortypesofcataractthatarenameddependingonthelocationwithinthelensthatismostaffected.Thesearecortical,nuclearandposteriorsubcapsular.Agivenlensmayhavecomponentsofallthreetypesofcataract.根据晶状体开始出现混浊的部位，老年性白内障分为3种类型：皮质性、核性及后囊下白内障。一个晶状体可能同时发生这3型白内障。,Corticalcataract,themostcommontypeofage-relatedcataract.fourstagesasfollows:,Incipientstage初发期,Corticalchangesmaybeginassmallperipheralwaterclefts.皮质中空泡和水隙形成。Radicalpatternopacity.放射状混浊。检眼镜检查可见红光反射中放射状或片状阴影。早期较周边的混浊并不影响视力，病程发展慢。,初发期,Intumescentstage肿胀期,Thelenstakesupwater,itbecomesintumescent.混浊加重，皮质吸水肿胀，晶状体体积增大。Anteriorchambergetsshallow.前房变浅，有闭角型青光眼体质者可诱发青光眼急性发作。斜照法检查虹膜投影现象。视力明显下降，眼底难以窥清。,肿胀期,Maturestage成熟期,Liquidescapesandthelensshrinks.晶体内水分溢出，肿胀消退，体积变小。Thelensproteinistotallyopaque.晶体完全混浊，呈乳白色。视力降至手动或光感，眼底不能窥入。,成熟期,HypermatureStage过熟期,Along-standingorverymaturecataractmayundergoliquefactionofthelenscortex.Thisliquidmayescapethroughtheintactcapsule,leavingashrunkenlenswithawrinkledcapsule.在过度成熟的白内障，晶状体皮质液化。囊内水分可溢出、肿胀消退，体积变小，囊膜发生皱缩。,Thedarkbrown,maturenucleuswhichsinksinferiorlyinthefluidfilledcapsularsacduetotheforcesofgravity.iscalledaMorgagniancataract.过熟期，棕黄色的晶状体核在囊内因重力而下沉，称为Morgagnian白内障。核下沉可使患者视力突然提高。,过熟期,hypermature,mature,Morganian,Nuclearcataract,Earlyonset(aftermiddleage).起病早，一般中年后开始。Theearliestsymptommaybeimprovednearvisionwithoutglasses(“secondsight”).早期症状可能是近视力改善（称为“二次视力”），这是由于白内障初期晶状体核屈光指数增加而产生近视所致。Othersymptomsmayincludepoorhuediscriminationormonoculardiplopia.其他症状可能包括颜色分辨力下降及单眼复视。,核性白内障,Posteriorsubcapsularcataract,Locatedinthecortexnearthecentralposteriorcapsule.位于后囊下浅皮质层。Ittendstocausevisualsymptomsearlierintheirdevelopmentowingtoinvolvementofthevisualaxis.混浊区位于视轴上，所以早期即可出现视力障碍。Commonsymptomsincludeglareandreducedvisionunderbrightlightingconditions.一般症状包括眩光、强光下视力下降。,后囊下型白内障,CongenitalCataract,Presentatbirthorappearshortlythereafter.于出生时或于生后短时间内即出现。Thesecataractsmayshowmanydifferentpatterns.Theopacitymaybeconfinedtotheareaoftheembryonicorfetalnucleuswithclearcortexsurroundingthis.形态学表现各异。混浊可能限于胎儿核周围。,Etiology病因学,Intra-uterine宫内因素virusinfection:风疹病毒、巨细胞病毒等感染MaternalingestionofThalidomide,steroids,孕期服用某些药物.Hereditary遗传因素autosomaldominant常染色体显性遗传多见recessive；X-linked隐性和伴性遗传,Clinicalfindings临床表现,anteriorpolarcataract：前极性白内障posteriorpolarcataract:后极性白内障coronarycataract:冠状白内障punctatecataract:点状白内障perinuclearcataract:绕核性白内障nuclearcataract:核性白内障totalcataract:全白内障membranouscataract:膜性白内障,后极部白内障,冠状白内障,核性白内障,Treatment,Avoidanceofamblyopia.视觉正常发育受影响，易产生形觉剥夺性弱视。Dense,central,largerthan2mmindiametercongenitalcataractsrequiresurgeryonanurgentbasis.位于中央且程度严重直径超过2mm则需尽早手术。,Traumaticcataract外伤性白内障,Concussion钝挫伤Penetrating穿通伤Electricshock电击伤Radiation辐射伤,眼球钝挫伤所致白内障,眼球穿通伤所致的白内障,电击所致的白内障,TREATMENT,影响视力不大的局限混浊，可随诊观察。明显混浊影响视力的，应行手术治疗。晶体破裂，皮质进入前房，可用糖皮质激素和降压药物，使病情控制后，手术摘出白内障，当皮质接触角膜内皮时，应考虑及早手术。白内障摘出后应尽量植入IOL。,metaboliccataract代谢性白内障,1.Diabeticcataract-Senilecataractisaccelerated合并老年性白内障-Truediabeticcataract真性糖尿病性白内障2.Galactosecataract半乳糖性白内障3.tetanycataract手足搐搦性白内障,糖尿病性白内障Diabeticcataract,临床表现糖尿病患者的年龄相关性白内障较多见，与无糖尿病的年龄相关性白内障相似，但发生较早，容易成熟。真性糖尿病性白内障多发生于30岁以下，病情严重的幼年型糖尿病患者。常为双眼发病，进展迅速，晶体可能在数天、数周或数月内全混浊。,治疗,应积极治疗糖尿病。在糖尿病白内障早期，严格控制血糖，晶体混浊可能会部分消退。当影响视力明显时，可在控制血糖下行白内障摘出术和IOL植入术，如有糖尿病性视网膜病变，宜在白内障手术前做视网膜光凝，手术后应继续治疗眼底病变。,半乳糖性白内障Galactosecataract,为常染色体隐性遗传。患儿缺乏半乳糖-1-磷酸尿苷转移酶和半乳糖激酶，使半乳糖不能转化为葡萄糖而在体内积聚。组织内的半乳糖被醛糖还原酶还原为半乳糖醇。醇的渗透性极强，在晶体内的半乳糖醇吸水后，晶体囊膜破裂，引起晶体混浊。,诊断与治疗,诊断：对先天性白内障患儿，应对尿中半乳糖进行筛选。如测定红细胞半乳糖-1-磷酸尿苷转移酶的活性，可明确诊断半乳糖-1-磷酸尿苷转移酶是否缺乏，应用放射化学法可测定半乳糖激酶的活性，有助于诊断。治疗：给予无乳糖和半乳糖食品，可控制病情的发展或逆转白内障。,手足搐搦性白内障tetanycataract,又称低钙性白内障，由血钙过低引起。低钙患者常有手足搐搦，因此又称手足搐搦性白内障。多由先天性甲状旁腺功能不足，或由于甲状腺手术损伤甲状旁腺以及营养不良所致。低钙增加了晶体囊膜的渗透性，影响了晶体的代谢。,临床表现：有手足搐搦、骨质软化和白内障三项典型改变。双眼晶体皮质前后皮质内有辐射状或条纹状混浊，与囊膜间有透明带隔开。囊膜下可见红、绿或蓝色结晶微粒。诊断：有甲状腺手术史或营养障碍史，血钙过低，血磷升高。治疗：给以足量的维生素D、钙剂，纠正低血钙，白内障明显时，可行手术治疗。,Complicatedcataract并发性白内障,Developasadirecteffectofeyediseasesuponthephysiologyofthelens,suchas：glaucoma，青光眼iritis，虹膜炎eyetumors，眼部肿瘤retinitispigmentosa，视网膜色素变性retinaldetachment，视网膜脱离,常有眼部原发病的表现。眼前段炎症疾病所致的由前皮质开始混浊。,临床表现,眼后段炎症所致在晶体后极部囊膜下皮质、晶体核中心部和周边部呈放射状，玫瑰花样混浊。,Drug-induced/toxiccataract药物或中毒性白内障,Steroids：糖皮质激素全身较局部使用发生率高Chlorpromazine：氯丙嗪Metals：金属（铜、铁、汞等）Miotics：缩瞳剂Trinitrotoluene：三硝基甲苯,AfterCataract后发性白内障,Opacifacationoftheposteriorcapsuleduetopartiallyabsorbedtraumaticcataractorfollowingextracapsularcataractextraction.Persistentsubcapsularlensepitheliummayfavorregenerationoflensfibers.晶状体外伤后或白内障囊外摘出（包括超声乳化）手术后，残留的皮质或晶状体上皮细胞增生，形成混浊。,After-cataracttreatment,Unlikeacataract,anafter-cataractistreatedwithatechniquecalledlasercapsulotomy.后发性白内障的治疗不同于其他类型白内障，激光囊膜切开是有效的方法。,Theneodymium:YAGlaserprovidesanoninvasivemethodfordiscissionoftheposteriorcapsule.Nd:YAG激光囊膜切开术是一种后囊切开的非侵入性方法。Pulsesoflaserenergycreatasmallholeintheposteriorcapsuleinthepupillaryaxis.激光能量瞬间传入靶组织引起小的“爆发”，于瞳孔轴心的后囊内造成一个小洞。,CataractTreatment,Surgeryistheonlywaytoremovethecataract.However,ifsymptomsfromacataractaremild,achangeofglassesmaybeallthatisneededforyoutofunctionmorecomfortably.Cataractsurgeryshouldbeconsideredwhencataractscauseenoughlossofvisiontointerferewithdailyactivities.,手术适应症,视力的原因医疗的原因美容的原因,术前准备,Whathappensbeforesurgery?,Aweekortwobeforesurgery,sometestsshouldbedone,including:Visualacuity,intraocularpressure,slitlamp,ophthalmoscopeTomeasurethecurveofthecorneaandthesizeandshapeoftheeye.systemicexam:hypertension,diabetesandotherdisorders,术前检查,全身检查三大常规、心电图、胸透、血压、血糖、肝功能、肾功能。局部检查视功能、眼压、冲洗泪道、角膜曲率、A/B超散瞳查晶体结膜囊细菌培养角膜内皮计数眼电生理检查(EOG、ERG、VEP),白内障手术,手术方法,白内障囊内摘除术(ICCE)白内障囊外摘除+人工晶体植入术(ECCE)小切口白内障摘除+人工晶体植入术超声乳化白内障摘除+人工晶体植入术,ECCE+IOL,Extracapsularcataractextractionisapreferredmethodofcataractsurgery.白内障囊外摘出术是目前主导的白内障手术。Itpreservestheposteriorportionofthelenscapsule.将混浊的晶状体核和皮质摘出而保留后囊膜。PosteriorchamberIOLcanbeimplantedinthecapsularsac.后房型人工晶体得以植入晶状体囊内。,Phacoemulsification,Phacoemulsificationorphacoreferstoultra-sonicvibrationwhichdissolvesthehardnucleussuchthatthenuclearmaterialandcortexcanbeaspiredthroughanincisionofapproximately3mm.超声乳化白内障吸除术是应用超声能量将混浊晶体核和皮质乳化后吸除，保留晶状体后囊。itisthekeytoadvanced,small-incisioncataractsurgery.手术切口小，时间短。,Complications手术并发症,posteriorcapsuleopacification后囊下混浊最常见cystoidmacularedema黄斑囊样水肿glaucoma青光眼hyphema眼前房出血ptosis上睑下垂infection眼内炎最严重retinaldetachment视网膜脱离lensdislocation人工晶体位置异常,CataractSurgery,Insertingthenewlens,白内障术后的视力矫正,白内障摘除后的无晶体眼呈高度远视状态一般达+8D+10D，矫正视力措施：人工晶体植入眼镜角膜接触镜,IntraocularLens,AnIOLisatiny,transparent,convexlensmadeofpolymerwhichisinsertedintheeyeduringsurgery.人工晶体是一种人工制造体积微小、透明的凸透镜，材料为高分子聚合物，具有良好的光学物理性能和组织相容性。,IOL可折式6mm,FoldableIOL,Anteriorchambertype,Posteriorchambertype,AdvantagesofIOL,Sincethelensisplacedinsidetheeye,thepatientneednotwearglassesfordistantvision.无需戴镜。Imagesareclearandofthesamedimensionwithoutdistortion.物像清晰，放大倍率小。Fullvisionisobtainedsoonaftersurgery.术后迅速恢复视力。,Whathappensaftersurgery?,Ifasmall-incisiontechniqueisused,thepostoperativerecoveryperiodisusuallyshortened.采用小切口手术方式可以缩短术后恢复期。Thepatientmaybeambulatoryonthedayofsurgerybutisadvisedtomovecautiouslyandavoidstrainingorheavyliftingforamonth.患者可能于手术当天即可自由行动，但是在一个月内应避免用力或