本文選題：原發(fā)性開角型青光眼 + 眼壓�。� 參考：《南方醫(yī)科大學(xué)》2016年碩士論文

【摘要】：青光眼是全球不可逆致盲性眼病的首要病因,因其發(fā)病的隱匿性和視神經(jīng)損害的不可逆性而極具危害。原發(fā)性開角型青光眼(primary open angle glaucoma, POAG)是一種慢性進(jìn)行性的視神經(jīng)病變,病理性眼壓升高是造成視神經(jīng)損害的主要危險(xiǎn)因素。既往眼壓在POAG的診斷過程中具有非常重要的地位,然而隨著大量正常眼壓性青光眼(normal-tension glaucoma,NTG)和高眼壓癥(ocular hypertention,OH)等病例的報(bào)道,高眼壓已不作為POAG診斷的必須指標(biāo),只要具有特征性的視神經(jīng)和視野損害表現(xiàn)、房角開放且無其他導(dǎo)致上述損害的病因即可診斷為POAG。但全球公認(rèn)降低眼壓是青光眼唯一有效的治療手段,由此形成了診斷與治療的原則相背離的尷尬局面。有研究者認(rèn)為青光眼是一種神經(jīng)退行性病變,與阿爾茨海默病和帕金森綜合征等神經(jīng)退行性疾病之間具有大量的相似性。為什么在眼壓正常的情況下仍然會(huì)發(fā)生青光眼視神經(jīng)損害,為什么在不對(duì)眼壓進(jìn)行任何干預(yù)的情況下90.5%的OH患者經(jīng)過5年的隨訪后并未發(fā)生視神經(jīng)的損害。跨篩板壓力差(trans-lamina cribrosa pressure difference,TLCPD)理論在青光眼視神經(jīng)損害中作用的揭示,使我們對(duì)以上問題有了新的認(rèn)識(shí),并提示我們青光眼仍然是一組與眼壓密切相關(guān)的疾病且同時(shí)受到顱內(nèi)壓等因素的影響。在POAG的診斷過程中我們是否仍然需要加強(qiáng)對(duì)眼壓的關(guān)注尚待大量臨床研究來論證。根據(jù)眼壓水平的不同,人們將POAG分為高眼壓性青光眼(high-tension glaucoma,HTG)和NTG。國(guó)外眼科流行病學(xué)研究結(jié)果顯示亞洲為NTG的高發(fā)地區(qū),POAG中NTG的比例高達(dá)52%-92%,在白色人種中該比例略低約為30%-38.9%,在非洲人種中約為57.1%。國(guó)內(nèi)的眼科流行病學(xué)研究結(jié)果亦顯示NTG為POAG的主要組成部分,NTG在POAG中的比例可達(dá)60%-90%。然而國(guó)外部分臨床機(jī)構(gòu)的研究結(jié)果顯示在臨床上以HTG更為常見,Gyasi等對(duì)Emmanuel眼科診所的455例POAG患者進(jìn)行統(tǒng)計(jì)分析得出NTG僅有32例,約占POAG的7%。在國(guó)內(nèi)關(guān)于臨床上NTG和HTG比例的報(bào)道少見。如同血壓一樣,眼壓同樣具有復(fù)雜的變化與波動(dòng),容易受到各種內(nèi)外在因素的影響,如年齡、體位、光照等,單次或少次的日間眼壓測(cè)量不足以為確定POAG的類型提供充分的依據(jù)。在臨床上POAG患者治療前的眼壓水平究竟如何,NTG占POAG的多大比例,而這個(gè)比例與中央角膜厚度、24小時(shí)眼壓的變化等因素是否有關(guān)等問題尚待探討,眼科流行病學(xué)研究與臨床眼科學(xué)研究得到的NTG比例的差異給予我們?cè)鯓拥膯⑹居写伎肌Ｑ蹓号c青光眼性視神經(jīng)或視野損害的發(fā)生發(fā)展有著密切而復(fù)雜的聯(lián)系。既往眾多研究表明,病理性的眼壓升高是發(fā)生青光眼視神經(jīng)損害或視野損害的主要危險(xiǎn)因素,局部降眼壓藥物可以有效的延緩或者阻止眼壓升高的患者青光眼視神經(jīng)損害的發(fā)生。眼壓既是臨床上確定治療目標(biāo)又是評(píng)價(jià)治療效果的一個(gè)非常重要的指標(biāo)。POAG患者確診時(shí)的視野損害程度關(guān)系到疾病的治療與進(jìn)展。Ren等研究得出青光眼視野缺損與眼壓之間存在正相關(guān),相關(guān)系數(shù)為0.57。然而在確診時(shí)POAG患者的眼壓與視野損害程度之間具有怎樣的關(guān)系,臨床上POAG患者確診時(shí)的視野損害情況如何,確診時(shí)的視野損害嚴(yán)重程度還與哪些因素相關(guān),國(guó)內(nèi)相關(guān)報(bào)道少見。鑒于以上,我們對(duì)廣州軍區(qū)武漢總醫(yī)院青光眼專家門診就診的POAG患者進(jìn)行了一年多的臨床觀察,以了解臨床上POAG患者治療前的眼壓水平及眼壓與POAG患者確診時(shí)視野損害程度的關(guān)系。本課題分為兩個(gè)部分：第一部分通過對(duì)我院青光眼專家門診就診的POAG患者治療前的眼壓水平與24小時(shí)眼壓的觀察,了解臨床上NTG和HTG的構(gòu)成比及該比例與中央角膜厚度(central corneal thickness,CCT)、24小時(shí)眼壓等因素的關(guān)系；第二部分通過對(duì)POAG患者確診時(shí)的視野損害嚴(yán)重程度、眼壓水平等因素的觀察,了解我院POAG患者確診時(shí)的視野損害狀況及其與眼壓等因素的關(guān)系。第一部分 原發(fā)性開角型青光眼患者治療前的眼壓水平分析目的了解臨床上原發(fā)性開角型青光眼患者治療前的眼壓水平,探討臨床上正常眼壓性青光眼與高眼壓性青光眼的構(gòu)成比以及中央角膜厚度和24小時(shí)眼壓對(duì)該構(gòu)成比的影響。方法收集2014年5月至2015年4月于廣州軍區(qū)武漢總醫(yī)院青光眼專家門診就診并符合納入標(biāo)準(zhǔn)的POAG患者。分析其治療前的隨機(jī)眼壓水平。分別依據(jù)患者用藥前的門診最大隨機(jī)眼壓值、CCT校正后的門診最大隨機(jī)眼壓值和CCT校正后的24小時(shí)眼壓峰值是否大于21mmHg,將患者分為HTG(眼壓21mmHg)和NTG(眼壓21mmHg)。比較不同的分類方法下,兩種類型POAG患者的例數(shù)和構(gòu)成比。不同年齡、不同性別的POAG患者的眼壓水平采用獨(dú)立樣本t檢驗(yàn)。不同分類方法下,兩兩之間的構(gòu)成比比較采用x2檢驗(yàn)。結(jié)果研究共納入POAG患者115例,其中男84例(73.04%),女31例(26.96%),男女比例2.7：1.0,年齡(47.68±15.74)歲。以患者雙眼中眼壓較高眼的眼壓值進(jìn)行分析,POAG患者治療前經(jīng)CCT校正后的門診最高隨機(jī)眼壓為：20mmHg者23眼(20.00%),20-30mmHg者51眼(44.35%),30-40mmHg者18眼(15.65%),40-50mmHg者13眼(11.30%),50mmHg者10眼(8.70%)。男性患者的眼壓(32.34±13.49)mmHg高于女性患者的眼壓(25.86±9.99)mmHg,40歲及以下患者的眼壓(36.03±13.62)mmHg高于40歲以上患者的眼壓(27.22±11.32) mmHg,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。分別以患者用藥前的門診最大隨機(jī)眼壓值、CCT校正后的門診最大隨機(jī)眼壓值和CCT校正后的24小時(shí)眼壓峰值進(jìn)行分類,HTG和NTG的患者例數(shù)和構(gòu)成比分別為95例(82.61%)和20例(17.39%),89例(77.39%)和26例(22.61%),109例(94.78%)和6例(5.22%)。依據(jù)門診最大隨機(jī)眼壓值進(jìn)行分類得到的NTG的構(gòu)成比小于依據(jù)CCT校正后的門診最大隨機(jī)眼壓值分類得到的NTG的構(gòu)成比,但兩者的差異無統(tǒng)計(jì)學(xué)意義(p0.05)。這兩種分類標(biāo)準(zhǔn)得出的NTG和HTG的構(gòu)成比分別與依據(jù)CCT校正后的24h眼壓峰值進(jìn)行分類得到的NTG和HTG的構(gòu)成比相比差異均具有統(tǒng)計(jì)學(xué)意義,后一種分類標(biāo)準(zhǔn)得到的NTG比例顯著較低(p0.05)。結(jié)論在我院青光眼專家門診就診的POAG患者中,依據(jù)不同的眼壓標(biāo)準(zhǔn)進(jìn)行分類得到的NTG的構(gòu)成比不同,若以CCT校正后的24小時(shí)眼壓峰值結(jié)果為判斷標(biāo)準(zhǔn),則NTG僅占POAG的極小部分。CCT可能不會(huì)影響總體的NTG比例,但會(huì)影響個(gè)體的POAG類型的判別。在POAG的診斷過程中,我們應(yīng)重視對(duì)眼壓動(dòng)態(tài)全面系統(tǒng)的分析。第二部分原發(fā)性開角型青光眼患者確診時(shí)視野損害程度的相關(guān)因素分析目的通過對(duì)原發(fā)性開角型青光眼患者確診時(shí)的視野、眼壓水平等因素的觀察,了解我院原發(fā)性開角青光眼患者確診時(shí)的視野損害狀況及其相關(guān)因素。方法收集2014年5月至2015年10月在廣州軍區(qū)武漢總醫(yī)院青光眼專家門診就診并符合納入標(biāo)準(zhǔn)的POAG患者。觀察患者確診時(shí)的視野和眼壓情況。以患者雙眼中視野損害較嚴(yán)重的眼進(jìn)行分析,根據(jù)確診時(shí)的視野損害程度分級(jí)將患者分為早期視野損害組(視野損害0-1級(jí))和中晚期視野損害組(視野損害2-5級(jí))。對(duì)兩組患者的確診年齡、性別、身體質(zhì)量指數(shù)(BMI)、青光眼相關(guān)癥狀、家族史、高度近視、CCT、眼壓等相關(guān)因素進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料采用t檢驗(yàn)；計(jì)數(shù)資料采用Z2檢驗(yàn),相關(guān)性分析采用Spearman雙變量相關(guān)分析法。結(jié)果研究共納入確診為POAG的患者113例(113眼),其中男80例(80眼),占70.80%,女33例(33眼),占29.20%,年齡14～81(48.73±17.02)歲,確診年齡為14～81(47.59±17.20)歲。早期視野損害組31例(27.43%),確診年齡為(52.81±16.57)歲,其中男性19例(61.29%),女性12例(38.71%),BMI為(22.00±4.72)kg/m2,具有青光眼相關(guān)癥狀的有9例(29.03%),具有明確青光眼家族史的有3例(9.68%),合并高度近視的有3例(9.68%),CCT為(533.12±29.79)μm,IOP為(23.67μ11.44) mmHg。中晚期視野損害組82例(72.57%),確診年齡為(45.62±17.12)歲,其中男性61例(74.39%),女性21例(25.61%),BMI為(23.24±3.08)kg/m2,具有青光眼相關(guān)癥狀的有44例(53.66%),具有明確青光眼家族史的有7例(8.54%),合并高度近視的有24例(29.27%),CCT為(536.93μ35.02)μm,IOP為(30.58μ12.13) mmHg。經(jīng)SPSS統(tǒng)計(jì)軟件統(tǒng)計(jì)分析后得出,早期損害組的眼壓低于中晚期損害組,確診時(shí)的年齡大于中晚期損害組,合并高度近視眼的患者比例小于中晚期損害組,具有青光眼相關(guān)癥狀的患者比例小于中晚期損害組,差異均有統(tǒng)計(jì)學(xué)意義(均為P0.05)；早期損害組的性別比例、BMI、青光眼家族史、CCT與中晚期損害組相比,差異均無統(tǒng)計(jì)學(xué)意義(均為P0.05)。眼壓與POAG患者確診時(shí)的視野損害嚴(yán)重程度間呈正相關(guān)(r=0.411,P=0.000)。結(jié)論在我院青光眼專家門診就診的POAG患者中,大多數(shù)患者在確診時(shí)已經(jīng)發(fā)生了較嚴(yán)重的視野損害,高眼壓、具有青光眼相關(guān)癥狀、合并高度近視、確診時(shí)的年齡偏低可能是POAG患者確診時(shí)發(fā)生較嚴(yán)重視野損害的危險(xiǎn)因素。
[Abstract]:Glaucoma is the leading cause of irreversible blindness in the world. It is very harmful because of its occult and irreversible optic nerve damage. Primary open angle glaucoma (POAG) is a chronic progressive optic neuropathy. The rise of pathological intraocular pressure is the main risk cause of optic nerve damage. Previous intraocular pressure (TP) is very important in the diagnosis of POAG. However, with a large number of cases of normal-tension glaucoma (NTG) and high intraocular pressure (ocular hypertention, OH), high intraocular pressure (IOP) has not been used as a necessary indicator of POAG diagnosis as long as it has the characteristics of optic nerve and visual field damage. The open corner of the room and no other cause of the damage can be diagnosed as POAG., but the global recognition of IOP reduction is the only effective treatment for glaucoma, resulting in an awkward situation that deviates from the principle of diagnosis and treatment. There is a large number of similarities between neurodegenerative diseases such as syndrome. Why the optic nerve damage still occurs in normal intraocular pressure, and why 90.5% of OH patients without any interference in the intraocular pressure do not have optic nerve damage after 5 years of follow-up. Cross sieve plate pressure difference (trans-lamina cribros) The revelation of the role of a pressure difference (TLCPD) theory in glaucomatous optic nerve damage has brought us a new understanding of the above problems and suggests that glaucoma is still a group of diseases closely related to intraocular pressure and is affected by intracranial pressure. Whether we still need to strengthen the intraocular pressure during the diagnosis of POAG The attention has yet to be demonstrated in a large number of clinical studies. According to the level of intraocular pressure, POAG is divided into high-tension glaucoma (HTG) and NTG. foreign ophthalmological studies. The results show that Asia is a high incidence region of NTG, the proportion of NTG in POAG is as high as 52% -92%, and the proportion in white races is slightly lower to 30%-38.9%, The results of ophthalmologic epidemiological studies, about 57.1%. domestic, also show that NTG is the main component of POAG, and the proportion of NTG in POAG can reach 60%-90%.. However, the results of some foreign clinical institutions abroad show that HTG is more common in the clinic and Gyasi and other 455 POAG patients in the Emmanuel ophthalmology clinic are statistically analyzed. There are only 32 cases of NTG, and 7%. of about POAG is rare in domestic reports of the proportion of NTG and HTG in the clinic. Like blood pressure, intraocular pressure also has complex changes and fluctuations. It is easily affected by various internal and external factors, such as age, body position, light and so on. Single or fewer daytime intraocular pressure measurements are insufficient to provide the type of POAG. What is the level of intraocular pressure (IOP) before the treatment of POAG patients, the proportion of NTG to POAG, and whether the ratio is related to the central corneal thickness, the change of the 24 hour intraocular pressure and other factors, and what is the difference between the ophthalmologic and clinical ophthalmological studies on the proportion of NTG There is a close and complex link between intraocular pressure and the occurrence and development of glaucomatous optic nerve or visual field damage. Previous studies have shown that elevated intraocular pressure is the main risk factor for optic nerve damage or visual field damage in glaucoma. Local intraocular pressure drops can effectively delay or prevent intraocular pressure from rising. The occurrence of optic nerve damage in patients with glaucoma. Intraocular pressure is a very important index to determine the target of treatment and to evaluate the effect of the treatment. The degree of visual field damage in.POAG patients is related to the treatment and progress of.Ren. The correlation between glaucoma visual field defect and ocular pressure is positive, and the correlation coefficient is 0.57. However, what is the relationship between the intraocular pressure and the degree of visual field damage at the time of diagnosis of POAG patients; what is the relationship between the visual field damage at the diagnosis of POAG patients and what factors are related to the severity of the visual field damage at the time of diagnosis, and the domestic related reports are rare. The POAG patients underwent more than one year of clinical observation to understand the relationship between intraocular pressure (IOP) and intraocular pressure (IOP) before treatment of POAG patients and the degree of visual field damage in patients with POAG. The subject was divided into two parts: the first part was the intraocular pressure level and 24 hour eyes before the treatment of the POAG patients in the glaucoma specialist clinic in our hospital. The relationship between the ratio of NTG and HTG, the ratio of the central corneal thickness (central corneal thickness, CCT), and the 24 hour intraocular pressure (IOP), and the second part by observation of the severity of the visual field damage and the level of intraocular pressure in the diagnosis of POAG patients, to understand the visual field damage at the diagnosis of POAG patients in our hospital. An analysis of intraocular pressure (IOP) before treatment for primary open angle glaucoma. Objective to understand the level of intraocular pressure (IOP) before treatment in patients with primary open angle glaucoma, and to explore the composition ratio of normal intraocular pressure glaucoma and ocular hypertension, as well as the thickness of the central cornea and 24 small. Methods the effect of intraocular pressure on the composition ratio. Methods POAG patients were collected from May 2014 to April 2015 in the specialist clinic of glaucoma specialist in Wuhan General Hospita of Guangzhou Military Region. The level of random intraocular pressure (IOP) before treatment was analyzed. The maximum random eye pressure of the outpatient before medication, the maximum random eye after CCT correction, was analyzed. Whether the peak value of intraocular pressure (IOP) was greater than 21mmHg after 24 hours of pressure and CCT correction, the patients were divided into HTG (intraocular pressure 21mmHg) and NTG (IOP 21mmHg). Under different classification methods, the number and composition of the two types of POAG patients were compared. The intraocular pressure of the POAG patients of different ages and sex of the POAG patients were tested by independent sample t test. Under different classification methods, 22 The composition ratio was compared with x2 test. The results were included in 115 cases of POAG patients, including 84 men (73.04%) and 31 women (26.96%). The proportion of men and women was 2.7:1.0 and age (47.68 + 15.74) years. The intraocular pressure of the patients with higher eye pressure in the eyes was analyzed. The maximum random intraocular pressure (LOP) of the POAG patients after CCT correction was: 20mmHg 23. Eyes (20%), 20-30mmHg 51 eyes (44.35%), 18 eyes (15.65%), 13 eyes (11.30%) of 40-50mmHg and 10 eyes of 50mmHg (8.70%). The intraocular pressure (32.34 + 13.49) mmHg of male patients was higher than that of female patients (25.86 + 9.99) mmHg, and intraocular pressure (mmHg) of mmHg was higher than that of patients above. The difference was statistically significant (P0.05). The maximum random intraocular pressure (IOP) before the patient was used, the maximum random intraocular pressure after CCT correction and the 24 hour intraocular pressure peak after the CCT correction were classified. The number and the composition ratio of HTG and NTG were 95 cases (82.61%) and 20 cases (17.39%), 89 cases (77.39%) and 26 cases (22.61%), 109 cases (94.78%). And 6 cases (5.22%). The composition ratio of NTG obtained according to the maximum random IOP value of the outpatient was less than that of the NTG which was classified according to the maximum random intraocular pressure (IOP) based on the CCT correction, but the difference between the two was not statistically significant (P0.05). The ratio of NTG and HTG to the CCT corrected 24h, respectively, was obtained by the two classification standards. The composition of NTG and HTG of the peak value of intraocular pressure was statistically significant compared with that of the latter, and the NTG ratio obtained by the latter classification standard was significantly lower (P0.05). Conclusion in the POAG patients who were diagnosed with glaucoma experts in our hospital, the constituent ratio of NTG based on the different intraocular pressure criteria was different, if CCT was corrected. The 24 hour peak of intraocular pressure (IOP) of 24 hours is the criterion, and the minimal part.CCT of POAG may not affect the overall NTG ratio, but it will affect the discrimination of the individual POAG type. In the diagnosis of POAG, we should attach importance to the analysis of the dynamic comprehensive system of intraocular pressure. The second part of the primary open angle glaucoma patients with the diagnosis of visual field loss. Objective to understand the visual field and related factors of primary open angle glaucoma patients in our hospital by observing the visual field of the diagnosis of primary open angle glaucoma and the level of intraocular pressure. Methods the methods collected from May 2014 to October 2015 were collected at the Wuhan General Hospita of Guangzhou Military Region. POAG patients who were treated in the home outpatient department were met with the standard of the patient. Observe the visual field and intraocular pressure in the patient's diagnosis. The patients were divided into the early visual field damage group (0-1 levels of visual field damage) and the middle and late visual field damage group (2-5 levels of visual field damage) according to the degree of visual field damage at the time of diagnosis. A statistical analysis was made of the related factors of two groups of patients: age, sex, body mass index (BMI), glaucoma related symptoms, family history, high myopia, CCT, intraocular pressure and other related factors. The measurement data were tested by t test, the count data were examined by Z2 test, and the correlation analysis was analyzed by Spearman bivariate correlation analysis. The results were included in the diagnosis of POAG. There were 113 patients (113 eyes), of which 80 were male (80 eyes), 70.80%, 33 (33 eyes), 29.20% and 14~81 (48.73 + 17.02) years old. The age of diagnosis was 14~81 (47.59 + 80) years old. There were 9 cases (29.03%) of ocular related symptoms, 3 cases (9.68%) with a clear family history of glaucoma, 3 cases with high myopia (9.68%), CCT (533.12 + 29.79) mu m, and IOP (23.67 u 11.44) mmHg. middle and late visual field damage group (72.57%). 24 + 3.08) kg/m2, 44 cases (53.66%) with glaucoma related symptoms, 7 cases (8.54%) with a clear family history of glaucoma, 24 cases (29.27%) with high myopia (29.27%), and CCT (536.93 u 35.02) mu m, IOP (30.58 Mu 12.13) mmHg. after SPSS statistical software analysis, the intraocular pressure of early damage group was lower than that of the middle and late stage damage group and confirmed at the time of diagnosis. The proportion of patients with high myopia was less than that of middle and late stage damage group. The proportion of patients with glaucoma related symptoms was less than that of middle and late stage damage group, and the difference was statistically significant (P0.05). The sex ratio, BMI, family history of glaucoma in early damage group, CCT and middle and late damage group were all different. There was no statistical significance (all P0.05). Intraocular pressure was positively correlated with the severity of visual field damage at the time of diagnosis of POAG (r=0.411, P=0.000). Conclusion in the POAG patients who were diagnosed with glaucoma experts in our hospital, most of the patients had severe visual field damage, high intraocular pressure, glaucoma associated symptoms, combined with high close proximity. The low age at diagnosis may be a risk factor for severe visual field damage in POAG patients.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R775.2

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