临床案例Clinicalcase病理性近视致低视力康复Rehabilitationoflowvis

临床案例Clinicalcase病理性近视致低视力康复Rehabilitationoflowvisionduetopathologicalmyopia目录Contents病历摘要Abstractofmedicalrecord第一部分Part1病例分析Caseanalysis第二部分Part2疾病介绍Introductiontodisease第三部分Part3教学病例讨论Teachingcases教学病例讨论Teachingcases病例摘要第一部分Part1Abstractofmedicalrecord一、患者基本信息Basicinformationofpatient患者，男性，51岁。Patient,male,51yearsold.主诉：自幼双眼视物模糊，加重近5年。Blurredvisioninbotheyessincechildhood,aggravatedfornearly5years.既往史：患者既往体健，否认高血压、糖尿病等病史，否认药物过敏史，否认眼部及其他全身手术病史。Previoushistory:Thepatientwasingoodhealthanddeniedmedicalhistoryofhypertension,diabetes,drugallergy,andeyeandothersystemicoperations.现病史：患者自幼视物模糊，诊断为“双眼近视”,一直坚持配戴眼镜，近5年来自觉双眼戴镜视力明显下降。发病以来，神志清，精神可，生命体征平稳，二便正常。Historyofpresentdisease:Thepatienthadblurredvisionsincechildhoodandwasdiagnosedas"binocularmyopia".Healwaysinsistedonwearingglassesandfeltthathisbinocularvisionhaddecreasedsignificantlyinthepast5years.Sincetheonset,themindisclear,thespiritcan,thevitalsignsarestable,andthebowelisnormal.体格检查：体健，全身及一般状态未见明显异常。Physicalexamination:healthy,noobviousabnormalityingeneralbodyandgeneralstate.一、患者基本信息Basicinformationofpatient眼科检查Eyeexamination检查项目

主要内容

OD(D)OS(D)OU(D)检查项目Checkitem

主要内容Maincontents

OD(D)OS(D)OU(D)原远用处方

远距-12.00D=4.0(0.1)

-12.00D=4.0(0.1)

4.0(0.1)Originalfarsightednessprescription近距-12.00D=4.0(0.1)

-12.00D=4.0(0.1)

4.0(0.1)主觉验光

远距-19.00/-1.00×90=4.3(0.2)-14.00/2.50×90=4.3(0.2)4.3(0.2)Subjectiverefraction近距-17.00/-1.00×90=4.3(0.2)-12.00/2.50×90=4.3(0.2)4.4(0.25)眼压Intraocularpressure16.3mmHg15.2mmHg对比敏感度视力0.640.64Contrastsensitivityvision对比视野Contrastfieldofview

视野缩窄Narrowingofvisualfield

视野缩窄Narrowingofvisualfield角膜映光法检查keratoscopy

正位Rightposition遮盖试验Coveringtestexo,-8△@N&D眼球运动EyemovementSAFE裂隙灯检查Slit-lampexamination双眼睑形态正常，启闭可，结膜清，角膜透明，前房深清，虹膜纹理清，

瞳孔圆，对光反射正常，晶状体轻度混浊，玻璃体混浊

Normaleyelidshape,openandclose,conjunctivaclear,corneatransparent,anteriorchamberdeepclear,iristextureclear,

Thepupilisround,thelightreflexisnormal,thelensisslightlycloudy,thevitreousbodyiscloudy眼底检查Fundusexamination

视网膜豹纹状改变，C/D约0.2，视盘周围及黄斑区见脉络膜缩，

斑中心凹反光未见(图1-1)Leopardpatternchangesinretina,C/Dabout0.2,choroidalcontractionaroundopticdiscandmaculararea,Noreflectioninfovea(Figure1-1)一、患者基本信息Basicinformationofpatient特殊检查Specialexamination

(1)眼轴检查；OD31.86mm;

OS30.16mm。(1)Ocularaxisexamination;OD31.86mm;OS30.16mm.(2)眼底OCT:双眼黄斑区视网膜走行不平，局部表面反射粗糙。神经上皮层可见无反射区，部分视网膜萎缩且层次不清，RPE/CCL反射紊乱,不均匀增宽。(2)fundusOCT:theretinainthemacularareaofbotheyesisuneven,andthelocalsurfacereflectionisrough.Non-reflectiveareascanbeseenintheneurocorticallayer,someretinalatrophyandunclearlayers,RPE/CCLreflexdisorder,unevenwidening.(3)B超：双眼玻璃体轻度混浊，后巩膜葡萄肿。(3)B-ultrasound:slightopacityofvitreousbodyinbotheyesandposteriorscleralstaphyloma.一、患者基本信息Basicinformationofpatient特殊检查Specialexamination

特殊检查Specialexamination

(4)视野检查：双眼生理盲点扩大，右眼鼻侧下方视野缩小，左眼下方及颞侧视野缩小。(4)Visualfieldexamination:thephysiologicalblindspotofbotheyesisenlarged,thevisualfieldbelowthenoseoftherighteyeisnarrowed,andthevisualfieldbelowthelefteyeandthetemporalfieldisnarrowed.一、患者基本信息Basicinformationofpatient特殊检查Specialexamination

二、诊断判定疾病过程Diagnosisanddeterminationofthediseaseprocess【诊断】【Diagnosis】①二级低视力①Grade2lowvision②双眼病理性近视②Pathologicalmyopiaofbotheyes③并发性白内障③Complicatedcataract【治疗】【Treatment】

病理性近视眼目前尚无特异性治疗方法，主要进行屈光矫正及低视力康复，如出现并发症则对症治疗。

Atpresent,thereisnospecifictreatmentforpathologicalmyopia,mainlyrefractivecorrectionandlowvisionrehabilitation,andsymptomatictreatmentifcomplicationsoccur.

病理性近视的治疗思路，首先是矫正屈光不正，可以通过配戴框架眼镜、角膜接触镜、角膜屈光手术或有晶体眼人工晶体植入

手术。

Thetreatmentideaofpathologicalmyopia,thefirstistocorrecttherefractiveerror,canbebywearingframeglasses,cornealcontactlenses,cornealrefractivesurgeryorintraocularlensimplantationsurgery.

对于进展性近视，如有需要可以行后巩膜加固手术。

Forprogressivemyopia,posteriorscleralreinforcementsurgerymaybeperformedifnecessary.

另外，病理性近视患者，容易发生并发性白内障，如发生白内障，可以行白内障手术治疗；发生视网膜脱离，可以行激光治疗或

视网膜脱离修复手术治疗；对视网膜下新生血管膜及黄斑出血者，采取抗VEGF治疗、激光治疗及光动力学治疗等。

Inaddition,patientswithpathologicmyopiaarepronetocomplicatedcataract,suchascataract,cataractsurgerycanbeperformed;Retinaldetachmentcanbetreatedwithlasertherapyorretinaldetachmentrepairsurgery.Thepatientswithsubretinalneovascularizationmembraneandmacularhemorrhageweretreatedwithanti-VEGFtherapy,lasertherapyandphotodynamictherapy.二、诊断判定疾病过程Diagnosisanddeterminationofthediseaseprocess康复Rehabilitation1.康复需求及日常生活能力评估1.Assessmentofrehabilitationneedsanddailylivingability患者为51岁男教师，通过沟通和交流，得知患者在工作中需要批改学生作业，且平时有阅读纸质书本，喜欢用手机浏览新闻，因为近距离看不清晰，影响工作效率；远距离不能看清楚学生的上课反应等前来就诊。患者希望能够借助康复手段，让自己近距离工作更加顺利，并能更清楚地看清远距离物体。另外，患者还有一个困扰觉得自己配戴的镜片太厚重，影响外观和舒适度，希望能改善外观。Thepatientisa51-year-oldmaleteacher.Throughcommunicationandcommunication,Ilearnedthatthepatientneedstocorrectstudents'homeworkatwork.Besides,heusuallyreadspaperbooksandlikestobrowsenewsbymobilephone,becausehecannotseeclearlyatcloserange,whichaffectsworkefficiency.Hecametoseeadoctorbecausehecouldnotseehisstudents'reactionsinclassfromadistance.Patientshopetobeabletouserehabilitationmethodstomaketheircloseworkmoresmoothlyandtoseedistantobjectsmoreclearly.Inaddition,thepatientalsohasaproblemthatthelenshewearsistooheavy,affectingtheappearanceandcomfort,andhopestoimprovetheappearance.2.康复计划2.Rehabilitationplan(1)解释病史和康复计划(1)Explainmedicalhistoryandrehabilitationplan(2)视觉功能康复(2)Visualfunctionrehabilitation患者主觉验光：OD-19.00/-1.00×90=4.3(02)；OS-14.00/-2.50×90=4.3(0.2)；OU4.3(0.2)@D，ADD：+2.00DS，远距离给予全矫试戴略感头晕，无法适应。由于其左右眼也存在较大的屈光参差，且患者有看近需求，因此采用单眼视，将右眼球镜屈光度降低5.0D。此时，患者配戴舒适度增加，且自觉远近清晰度均可。

Patient'smainoptometry:OD-19.00/-1.00×90=4.3(02);OS-14.00/-2.50×90=4.3(0.2);OU4.3(0.2)@D,ADD:+2.00DS,slightlydizzyandunabletoadaptwhengivenfullcorrectionatadistance.Duetothelargeanisometropiaintheleftandrighteyes,andtheneedtoseeclosely,monocularvisionwasadopted,andtherighteyesphericaldiopterwasreducedby5.0D.Atthistime,thepatient'swearingcomfortincreases,andtheawarenessofdistanceandclaritycanbe.处方一：0D-14.00/-1.00×90=4.0(0.1);OS-14.00/-2.50×90=4.3(0.2)。Prescription1:0D-14.00/-1.00×90=4.0(0.1);OS-14.00/-2.50x90=4.3(0.2).处方二：配RGP镜片OD-15.5DS=4.4(0.25);OS-12.00DS=4.4(0.25)、0U4.4(0.25)。Prescription2:WithRGPlensOD-15.5DS=4.4(0.25);OS-12.00DS=4.4(0.25),0U4.4(0.25).

康复Rehabilitation

近视力康复：患者双眼的最佳矫正近视力均为0.2,考虑患者需要经常批改作业及阅读需求，由于患者舒适阅读的视力需求为4.5(0.3)-4.6(0.4),40cm视力为4.3(0.2),如提高到4.6(0.4),则阅读距离移到20cm,则需要5.0D的调节。Nearvisionrehabilitation:Thebestcorrectednearvisioninbotheyesofthepatientswas0.2.Consideringthatthepatientsneededtocorrecthomeworkandreadfrequently,andsincethevisualrequirementforcomfortablereadingis4.5(0.3)-4.6(0.4),andthevisualacuityof40cmis4.3(0.2),ifthereadingdistanceisimprovedto4.6(0.4),5.0Dadjustmentisrequiredwhenthereadingdistanceismovedto20cm.康复Rehabilitation因此，提高近视力的方法有以下几种：Therefore,thereareseveralwaystoimprovenearvision:①双眼近用处方OD-14.00/-1.00×90；OS-9.00/-2.50×90,视力可以达到0.5。②采用上述提及的单眼视屈光矫正(一只眼看远，一只眼看近):OD-14.00/-1.00×90;OS-14.00/-2.50×90。③双眼仍然在40cm处看近，OD-14.00/-1.00×90；OS-14.00/-2.50×90(远用处方)，此时左右眼近视力均4.3(0.2),再采用4x镇纸式放大镜视力可以达到4.8(0.6)；或者采用带超长臂自由活动放大镜视力可达4.6(0.4)。①PrescriptionOD-14.00/-1.00×90fornearuseofbotheyes;OS-9.00/-2.50×90,visioncanreach0.5.②Usethemonocularrefractivecorrectionmentionedabove(oneeyefar,oneeyenear):OD-14.00/-1.00×90;OS-14.00/-2.50x90.③Botheyesarestilllookingcloseat40cm,OD-14.00/-1.00×90;OS-14.00/-2.50×90(distantprescription),atthistime,thenearvisionoftheleftandrighteyesare4.3(0.2),andthevisionofthe4xpaperweightmagnifyingglasscanreach4.8(0.6);Oruseafreemovingmagnifyingglasswithanextralongarmtoachieveavisionof4.6(0.4).建议患者近用眼镜式助视器(批改作业、阅读等)、镇纸式放大镜(阅读)、带长臂放大镜(批改作业)配合使用。对于电子产品的阅读，可以使用手机或电脑本身的放大软件APP,以及手机设置中的字体大小，选择特大字体。Itisrecommendedthatpatientsusecloseglasses(correctinghomework,reading,etc.),paperweightmagnifyingglass(reading),andmagnifyingglasswithlongarm(correctinghomework)together.Forthereadingofelectronicproducts,youcanusetheenlargingsoftwareAPPofthemobilephoneorcomputeritself,aswellasthefontsizeinthemobilephoneSettings,selectalargefont.康复Rehabilitation

3)远视力康复：患者远视力4.3(0.2),自觉日常生活中行走等没有问题，但无法看清楚课堂上学生的课堂表现，给予患者4x单筒望远镜，视力可达4.8(0.6),用于看远处细节时使用。

3)Farvisionrehabilitation:Thepatienthasafarvisionof4.3(0.2)andnoproblemsinwalkingindailylife,butcannotseethestudents'classroomperformanceclearly.Thepatientisgiven4xmonocularswithavisionupto4.8(0.6),whichisusedforseeingdistantdetails.4)视野康复：由于周边视网膜变性，周边视野略有缩小，可考虑扩大视野康复。予以倒置望远镜试戴，患者觉视力下降明显，看不清眼前细节，自觉目前没有这样的需求，建议暂时不采用增大视野的装置，告知独立行走时务必小心周边，需要频繁转动头位来留意周边视野情况，避免碰撞。

4)Visualfieldrehabilitation:Duetoperipheralretinaldegeneration,theperipheralvisualfieldisslightlyreduced,andyoucanconsiderexpandingvisualfieldrehabilitation.Totryontheinvertedtelescope,thepatientfeelsthatthevisualacuityhasdecreasedsignificantly,cannotseethedetailsinfrontoftheeyes,consciousthatthereisnosuchneed,itisrecommendednottousethedevicetoincreasethevisualfieldforthetimebeing,informedthatwhenwalkingindependently,becarefulaboutthesurrounding,needtofrequentlyturntheheadtopayattentiontotheperipheralvision,toavoidcollision.5)其他康复措施：由于近距离戴框架眼镜时工作距离相对较近(20cm),长时间工作会导致肩颈部酸痛，建议使用阅读架或调整桌面高度，改善舒适度；同时，建议近距离工作时，使用较强的照明，并且推荐使用长灯臂、亮度可调节的落地灯

5)Otherrehabilitationmeasures:Becausetheworkingdistanceisrelativelyclose(20cm)whenwearingframeglassesatcloserange,theshoulderandneckwillbesorewhenworkingforalongtime.Itisrecommendedtouseareadingrackoradjusttheheightofthedesktoimprovecomfort;Atthesametime,itisrecommendedtousestronglightingwhenworkingincloseproximity,anditisrecommendedtouseafloorlampwithalonglamparmandadjustablebrightness康复Rehabilitation6)康复训练：首先在康复护士和医师的帮助下，教会患者使用助视器，并告知每种助视器的优点及局限性，以及适用于何种距离场景，并分别对每一种助视器的使用进行培训。6)Rehabilitationtraining:Firstofall,withthehelpofrehabilitationnursesanddoctors,teachpatientstousevisualAIDS,andinformeachoftheadvantagesandlimitationsofvisualAIDS,aswellassuitableforwhatdistancescenes,andconducttrainingontheuseofeachkindofvisualAIDS.7)心理康复：通过对患者的心理问卷的自评法及医师、护士在康复过程中的他评法，初步判断患者的心理健康情况，该患者有轻度焦虑倾向，主要问题在于担心自己的视力会进一步下降，影响生活和工作。针对患者的顾虑，通过对高度近视可能导致的并发症进行进一步的解释，告知患者定期做眼底检查，如有问题积极处理，打消患者的顾虑。7)Psychologicalrehabilitation:Throughtheself-evaluationofthepatient'spsychologicalquestionnaireandtheotherevaluationofdoctorsandnursesintherehabilitationprocess,thepatient'smentalhealthwasinitiallyjudged.Thepatienthadamildanxietytendency,andthemainproblemwasthathewasworriedthathisvisionwouldfurtherdeclineandaffecthislifeandwork.Inviewoftheconcernsofpatients,throughfurtherexplanationofthecomplicationsthatmaybecausedbyhighmyopia,patientsareinformedtodofundusexaminationregularly,andifthereisaproblem,activelydealwithittodispeltheconcernsofpatients.康复Rehabilitation【随访】【Follow-up】(1)低视力专科每3个月随访1次。(1)Lowvisionspecialistfollowupatevery3months.(2)眼底内科每半年随访1次，散瞳检查眼底情况。(2)fundusmedicalfollow-uponceeverysixmonths,mydriasisexaminationfundusconditions.随访Follow-upvisit教学病例讨论Teachingcases

病例分析Caseanalysis第二部分Part2分析Analysis【病例特点】【CaseCharacteristics】患者为双眼病理性近视导致的视觉功能障碍，视觉功能发生了不可逆转的损害。患者为中年男性，在职教师，目前仍在工作，有明显的看近与看远的视觉康复需求。Thepatienthasvisualdysfunctioncausedbypathologicalmyopiaofbotheyes,andthevisualfunctionhasbeenirreversiblydamaged.Thepatientisamiddle-agedmale,ateacher,whoisstillworkingatpresent,andhasobviousvisualrehabilitationneedsforseeingnearandfar.【诊断思路】【Diagnosticthinking】患者病史、专科检查和辅助检查资料均明确，无须鉴别。Thepatient'shistory,specialtyexaminationandauxiliaryexaminationdatawereclearanddidnotneedtobeidentified.【治疗思路】【Therapeuticidea】病理性近视的治疗思路，首先是矫正屈光不正，可以通过配戴框架眼镜、角膜接触镜(如RGP)、角膜屈光手术或ICL晶体植入手术，如有需要可以进行后巩膜加固手术。另外，病理性近视患者，容易发生并发性白内障，如发生白内障，可以行白内障手术治疗；发生视网膜脱离，可以行激光治疗或视网膜脱离修复手术治疗；发生脉络膜新生血管，则需要进行抗新生血管治疗。Thetreatmentideaofpathologicalmyopiaistocorrecttherefractiveerrorfirst,bywearingframeglasses,cornealcontactlenses(suchasRGP),cornealrefractivesurgeryorICLlensimplantationsurgery,ifnecessary,posteriorscleralreinforcementsurgery

canbeperformedtostrengthenthesclera.Inaddition,patientswithpathologicmyopiaarepronetocomplicatedcataract,suchascataract,cataractsurgerycanbeperformed;Retinaldetachmentcanbetreatedwithlasertherapyorretinaldetachmentrepairsurgery.Ifchoroidalneovascularizationoccurs,antineovascularizationtherapyisrequired.康复思路Rehabilitationthinking(1)根据患者的年龄、职业、目前的眼部情况及康复需求，给予患者看远、看近的视觉功能康复，来满足患者批改作业、看书、使用手机的需求，以及看清楚远处细节的需求。(1)Accordingtothepatient'sage,occupation,currenteyeconditionandrehabilitationneeds,givepatientsthevisualfunctionrehabilitationofseeingfarandneartomeettheneedsofpatientstocorrecthomework,readbooks,usemobilephones,andseeclearlydistantdetails.(2)由于周边视网膜变性，周边视野损害，如有需要，可以安排视野康复和行走技能的康复。(2)Duetoperipheralretinaldegenerationandperipheralvisualfielddamage,visualfieldrehabilitationandwalkingskillsrehabilitationcanbearrangedifnecessary.(3)由于近距离阅读距离较近，可以使用阅读架改善舒适度，并提供带长臂的强照明。(3)Duetotheclosereadingdistance,readingstandscanbeusedtoimprovecomfortandprovidestronglightingwithlongarms.(4)通过心理问卷自评法和他评法，发现该患者为轻度焦虑，针对患者的担心问题，医师给予详细的讲解，打消其顾虑。(4)Throughthepsychologicalquestionnaireself-assessmentandotherassessmentmethod,itwasfoundthatthepatientwasmildlyanxious,andthedoctorgaveadetailedexplanationtothepatient'sworriestodispelhisconcerns.(5)患者经常需要使用电脑、手机等电子产品，可以使用电脑和手机的放大软件及使用大字体来帮助改善视觉效果。(5)Patientsoftenneedtousecomputers,mobilephonesandotherelectronicproducts,theycanusethecomputerandmobilephonemagnificationsoftwareanduselargefontstohelpimprovethevisualeffect.教学病例讨论Teachingcases

疾病介绍Introductiontodisease第三部分

Part3三、疾病介绍Diseaseintroduction病理性近视是因眼轴过度增长而造成的眼底后极部损害为特征的高度近视，它有以下几个特征：眼轴不断增长，眼球后极部向后扩张形成后巩膜葡萄肿；近视度数随年龄增长不断增加；造成眼球后极部视网膜与脉络膜的损害。Pathologicalmyopiaisahighmyopiacharacterizedbydamagetotheposteriorpoleofthefunduscausedbyexcessivegrowthoftheaxisoftheeye.Ithasthefollowingcharacteristics:theaxisoftheeyecontinuestogrow,andtheposteriorpoleoftheeyeballexpandsbackwardtoformposteriorscleralstaphyloma;Thedegreeofmyopiaincreasedwithage,

causingdamagetotheretinaandchoroidoftheposteriorpoleoftheeyeball.视力的减退可因并发性白内障、视网膜脱离、脉络膜新生血管等引起。病理性近视是我国引起低视力的主要病因之一，患者屈光度多在-10.00D以上甚至达-40.00D。我国是世界上近视眼最多的国家之一，目前我国高中生近视患病率达80%以上，病理性近视在人群中的患病率为1%～2%、随着儿童青少年近视发病年龄提前、进展增快，病理性近视的比率仍将上升，病理性近视导致的低视力风险也随之增加。Thelossofvisioncanbecausedbycomplicatedcataract,retinaldetachment,choroidalneovascularizationandsoon.PathologicalmyopiaisoneofthemaincausesoflowvisioninChina,andthediopterofpatientsismorethan-10.00Doreven-40.00D.Chinaisoneofthemostnearsightedcountriesintheworld,atpresent,theprevalenceofmyopiainhighschoolstudentsinourcountryismorethan80%,theprevalenceofpathologicalmyopiainthepopulationis1%~2%,withtheonsetofmyopiainchildrenandadolescents,therateofpathologicalmyopiawillcontinuetorise,andtheriskoflowvisioncausedbypathologicalmyopiawillalsoincrease.低视力特点Characteristicsoflowvision这些患者由于戴高屈光度的负透镜，而使得视网膜成像显著缩小、看远处物体时似乎更远一些，屈光不正-10.00D以上时，视网膜成像显著缩小、发生辨认困难，因而有些患者不愿意接受眼镜。若出现眼底等病变，矫正视力无法提高。Thesepatientsworenegativelenseswithhighdiopter,whichmadetheretinalimagesignificantlysmallerandappearedfartherawayfromdistantobjects,refractiveerrorsexceeding-10.00Dresultinsignificantretinalimagingreduction,leadingtodifficultiesinrecognition.病理性近视后期，各种并发症导致矫正视力无法提高。Advancedstagesofpathologicalmyopiacancausecomplicationsthatpreventimprovementincorrectedvision.不戴镜可获得较好的近视力，但患者的远点太近，如-15.00D的近视，远点在眼前6.7cm,长时间在6.7cm距离近读易发生疲劳和工作不便。Goodmyopiamightbeattainablewithoutglasses,farpointsintheaffectedeyearetooclose.Forinstance,with-15.00Dmyopia,thefarpointisapproximately6.7cminfrontoftheeye,causingfatigueandinconvenienceduringprolongedclosereadingwithadistanceof6.7cminfrontoftheeye.屈光矫正原则Theprincipleofrefractivecorrection病理性近视所致的低视力在康复方面的首要措施是仔细进行屈光检查，配戴合适的眼镜，改善远视力。Thefirststepsinrehabilitationoflowvisionduetopathologicalmyopiaaretaking