青光眼英語 ppt課件

1、,Glaucoma,,GOALS,確定視神經(jīng)結(jié)構(gòu)、功能,評估發(fā)展成POAG的風(fēng)險(xiǎn),確定處理方案,減少副作用,健康教育,Document the status of optic nerve structure, by clinical evaluation and imaging, and function, by visual field testing, on presentation。,GOALS,確定視神經(jīng)結(jié)構(gòu)、功能,評估發(fā)展成P

2、OAG的風(fēng)險(xiǎn),確定處理方案,減少副作用,健康教育,Identify patients at high risk of developing POAG,GOALS,確定視神經(jīng)結(jié)構(gòu)、功能,評估發(fā)展成POAG的風(fēng)險(xiǎn),確定處理方案,減少副作用,健康教育,Consider treatment of high-risk individuals to prevent or delay the development of POAG,GOALS,確定視

3、神經(jīng)結(jié)構(gòu)、功能,評估發(fā)展成POAG的風(fēng)險(xiǎn),確定處理方案,減少副作用,健康教育,Minimize the side effects of treatment and the impact of treatment on the patient’s vision, general health, and quality of life,GOALS,確定視神經(jīng)結(jié)構(gòu)、功能,評估發(fā)展成POAG的風(fēng)險(xiǎn),確定處理方案,減少副作用,健康教育,Educa

4、te and involve patients and appropriate family members/caregivers in the management of their condition,PURPOSE,To detect and manage patients at risk for developing glaucoma, prevent damage to the optic nerve, and preserv

5、e patients’ quality of life.,,避免視神經(jīng)損害避免發(fā)展成POAG,維持患者生活質(zhì)量,,DISEASE DEFINITION,A glaucoma suspect is an individual with clinical findings and/or a constellation of risk factors that indicate an increased likelihood of deve

6、loping POAG.,clinical findings,The that define a glaucoma suspect patient are characterized by one of the following in at least one eye in an individual with open anterior chamber angles by gonioscopy:,Appearance of the

7、optic disc or retinal nerve fiber layer that is suspicious for glaucomatous damage Enlarged cup-disc ratio Asymmetric cup-disc ratio Notching or narrowing of the neuroretinal rim Disc hemorrhage Nerve fiber layer de

8、fect,A visual field suspicious for glaucomatous damage in the absence of clinical signs of other optic neuropathies Arcuate bundle defect Nasal step Paracentral scotoma Altitudinal defect Larger mean pattern standar

9、d deviation,,,,Consistently elevated intraocular pressure (IOP) associated with normal appearance of the optic disc and retinal nerve fiber layer and with normal visual field test results,,This definition excludes known

10、secondary causes for open-angle glaucoma, such as pseudoexfoliation (exfoliation syndrome), pigment dispersion, and traumatic angle recession.,clinical findings 小結(jié),one of the following in at least one eye in an individua

11、l with open anterior chamber anglesAppearance of the optic disc or RNFL that is suspicious for glaucomatous damage A visual field suspicious for glaucomatous damage in the absence of clinical signs of other optic neuro

12、pathies Consistently elevated intraocular pressure (IOP) associated with normal appearance of the optic disc and retinal nerve fiber layer and with normal visual field test results,a constellation of risk factors,Higher

13、 IOPThe public health importance of early detection and management of these patients lies in the fact that individuals with ocular hypertension are at increased risk of developing glaucomatous optic neuropathy. The Ocu

14、lar Hypertension Treatment Study (OHTS) demonstrated the rate of untreated participants developing glaucomatous optic neuropathy to be 9.5% in 5 years and 22% at 13 years, or approximately 2% per year.,a constellation of

15、 risk factors,Older ageFamily history of glaucomaLower ocular perfusion pressure Lower systolic and diastolic blood pressure Thinner central corneaDisc hemorrhage Larger cup-to-disc ratio Larger mean pattern stand

16、ard deviation on threshold visual field testing,,Some studies have shown an association between type 2 diabetes mellitus and a higher prevalence and incidence of open-angle glaucoma; however, other studies have not found

17、 such a relationship. The preponderance of the evidence suggests that type 2 diabetes mellitus is associated with a higher prevalence of open-angle glaucoma.,,migraine headache, peripheral vasospasm, concurrent cardiovas

18、cular disease, systemic hypertension, and myopia. However, the association between these risk factors and the development of glaucomatous optic nerve damage has not been demonstrated consistently.,,While disc hemorrhage

19、, increased cup-disc ratio and larger mean pattern standard deviation are considered to be risk factors for the development of POAG, it can also be argued that these signs represent early optic nerve damage and unsuspect

20、ed glaucoma.,CARE PROCESS,,DIAGNOSIS,The comprehensive initial glaucoma suspect evaluation (history and physical examination) includes all components of the comprehensive adult medical eye evaluation51 in addition to and

21、 with special attention to those factors that specifically bear upon the diagnosis, course, and treatment of POAG. The evaluation may require more than one visit. For instance, an individual might be suspected of having

22、POAG on one visit but may return for further evaluation to confirm the diagnosis, including additional IOP measurements, gonioscopy, central corneal thickness determination, visual field assessment, and optic nerve head

23、and retinal nerve fiber layer evaluation and documentation.,Ophthalmic Evaluation,成人眼部綜合評估+下列需要特別關(guān)注的眼部評估:病史 視力檢查瞳孔檢查 前節(jié)檢查眼底檢查眼壓測量前房角鏡檢查 視盤和視網(wǎng)膜神經(jīng)纖維層檢查,病史,眼部病史、家族史（尤其青光眼病史）、系統(tǒng)性疾病史（哮喘、偏頭痛、血管痙攣）?；仡櫹嚓P(guān)記錄,尤其關(guān)注眼壓和視神經(jīng)、視野

24、狀態(tài) 眼部和全身藥物治療 (糖皮質(zhì)激素) 以及局部或全身對藥物的敏感性（known local or systemic intolerance to ocular or systemic medications） 眼部手術(shù)：角膜屈光手術(shù)非常重要（角膜厚度下降，眼壓值偏低）。白內(nèi)障手術(shù)后眼壓偏低。,視力檢查,遠(yuǎn)視力：裸眼視力和矯正視力(矯正度數(shù))近視力：必要時(shí),瞳孔檢查,傳入性瞳孔障礙,眼前節(jié)檢查,裂隙燈檢查：窄房角（周邊淺前房和

25、前房角擁擠）角膜病變繼發(fā)眼壓升高的因素：剝脫綜合癥、色素播散、虹膜透照缺損、虹膜和房角新生血管、炎癥,眼壓檢查,檢查方法：NCT、修氏眼壓、壓平眼壓計(jì)在做其他檢查前先測眼壓：尤其前房角鏡和散瞳檢查記錄眼壓檢查具體時(shí)間：評估眼壓的日間變異24小時(shí)眼壓測量——評估眼壓的波動(dòng),前房角鏡檢查,排除以下因素：房角關(guān)閉繼發(fā)性原因造成眼壓升高房角后退色素dispersion周邊房角粘連房角新生血管炎癥沉著物 www.goni

26、oscopy.org,視盤和RNFL檢查,重要性：視盤改變、RNFL改變和視盤周圍的脈絡(luò)膜萎縮早于視野缺損。視盤出血是重要的體征。裂隙燈：散瞳下放大的立體像觀察直接檢眼鏡：作為補(bǔ)充，由于放大倍率更大，可以提供更多的細(xì)節(jié)。無赤光照明用于RNFL,眼底檢查,散瞳下的眼底檢查尋找可引起類似視盤和視野改變的眼底病變視神經(jīng)蒼白視盤玻璃疣視盤小凹 optic nerve pits中樞神經(jīng)系統(tǒng)疾病造成的視盤水腫黃斑變性視網(wǎng)膜血管阻塞

27、,Supplemental Ophthalmic Testing,中央角膜厚度視野視盤和視網(wǎng)膜神經(jīng)纖維層分析,中央角膜厚度,CCT和IOP之間相關(guān)性：沒有公認(rèn)的校正公式CCT是一個(gè)獨(dú)立于IOP的危險(xiǎn)因素（OHTS level II ）,視野檢查,自動(dòng)靜態(tài)視野檢查The frequency doubling technology (FDT) method with the central 20-degree test progr

28、am (C-20) short-wavelength automated perimetry (SWAP) with the central 24-degree test program (24-2) are two of several alternative testing methods to screen for a defect before conducting more definitive threshold test

29、ing比傳統(tǒng)的白-白視野檢查,,Careful manual combined kinetic and static threshold testing (e.g., Goldmann visual fields) is an acceptable alternative when patients cannot perform automated perimetry reliably or if it is not availabl

30、e.[A:III] Repeat, confirmatory visual field examinations may be required for test results that are unreliable or show a new glaucomatous defect before changing management.110,111 [A:III] In the OHTS, 86% of visual field

31、defects were not confirmed upon subsequent testing.110 It is best to use a consistent examination strategy for visual field testing.,視盤和視神經(jīng)纖維層分析,Color stereophotographycomputer-based imagingconfocal scanning laser oph

32、thalmoscopyoptical coherence tomographyscanning laser polarimetry,MANAGEMENT,對于青光眼或疑似患者，眼壓是唯一可調(diào)控因素 決定開始降眼壓治療是一個(gè)復(fù)雜的過程：眼科醫(yī)生對檢查結(jié)果的判斷風(fēng)險(xiǎn)評估患者的評估患者的選擇與患者（家屬）探討：危險(xiǎn)因素的數(shù)量和嚴(yán)重程度，預(yù)后、診療計(jì)劃、治療一旦開始就要長期堅(jiān)持恰當(dāng)?shù)闹委煼桨福航笛蹓盒Ч?、副作用、依從?何時(shí)開

33、始治療？,Any patient who shows evidence of optic nerve deterioration based on optic nerve head appearance, retinal nerve fiber layer loss, or visual field changes consistent with glaucomatous damage has developed POAG and sh

34、ould be treated as described in the Primary Open-Angle Glaucoma PPP.119 [A:III] Development of subtle abnormalities in the optic disc and retinal nerve fiber layer are best detected by comparing periodic fundus imaging w

35、ith disc and retinal nerve fiber layer photography and computerized imaging of the optic nerve and nerve fiber layer.81,120,,A new visual field defect that is consistent with a pattern of glaucomatous visual field defect

36、, confirmed on retesting of visual fields, may indicate that the patient has developed POAG.110,121 ? A patient who demonstrates very high IOP in which optic nerve damage is likely to occur may require treatment.,,In so

37、me cases, initiating treatment to lower the risk of glaucomatous damage may be appropriate if the patient has risk factors for glaucoma, such as optic nerve appearance, that is very suspicious for glaucomatous damage, a

38、strong family history of glaucoma, borderline visual field test findings, African American heritage, high myopia, or pseudoexfoliation (exfoliation syndrome). Whatever the scenario, a discussion must occur between the p

39、hysician and patient to outline the risks and benefits of treatment versus nontreatment.,目標(biāo)眼壓,目標(biāo)眼壓：20%基線眼壓基線眼壓？,治療的選擇,首選：藥物治療考慮因素：費(fèi)用、副作用、用法首選：前列腺素衍生物、β-受體阻滯劑用法：單眼治療法、多次基線測量,隨訪,病史：隨訪期間眼部病史隨訪期間全身疾病和治療史如果有進(jìn)行藥物治療，要注意藥