原发性开角型青光眼患者眼压状况的临床研究

发布时间：2018-06-05 12:54

本文选题：原发性开角型青光眼 + 眼压　；参考：《南方医科大学》2016年硕士论文

【摘要】：青光眼是全球不可逆致盲性眼病的首要病因,因其发病的隐匿性和视神经损害的不可逆性而极具危害。原发性开角型青光眼(primary open angle glaucoma, POAG)是一种慢性进行性的视神经病变,病理性眼压升高是造成视神经损害的主要危险因素。既往眼压在POAG的诊断过程中具有非常重要的地位,然而随着大量正常眼压性青光眼(normal-tension glaucoma,NTG)和高眼压症(ocular hypertention,OH)等病例的报道,高眼压已不作为POAG诊断的必须指标,只要具有特征性的视神经和视野损害表现、房角开放且无其他导致上述损害的病因即可诊断为POAG。但全球公认降低眼压是青光眼唯一有效的治疗手段,由此形成了诊断与治疗的原则相背离的尴尬局面。有研究者认为青光眼是一种神经退行性病变,与阿尔茨海默病和帕金森综合征等神经退行性疾病之间具有大量的相似性。为什么在眼压正常的情况下仍然会发生青光眼视神经损害,为什么在不对眼压进行任何干预的情况下90.5%的OH患者经过5年的随访后并未发生视神经的损害。跨筛板压力差(trans-lamina cribrosa pressure difference,TLCPD)理论在青光眼视神经损害中作用的揭示,使我们对以上问题有了新的认识,并提示我们青光眼仍然是一组与眼压密切相关的疾病且同时受到颅内压等因素的影响。在POAG的诊断过程中我们是否仍然需要加强对眼压的关注尚待大量临床研究来论证。根据眼压水平的不同,人们将POAG分为高眼压性青光眼(high-tension glaucoma,HTG)和NTG。国外眼科流行病学研究结果显示亚洲为NTG的高发地区,POAG中NTG的比例高达52%-92%,在白色人种中该比例略低约为30%-38.9%,在非洲人种中约为57.1%。国内的眼科流行病学研究结果亦显示NTG为POAG的主要组成部分,NTG在POAG中的比例可达60%-90%。然而国外部分临床机构的研究结果显示在临床上以HTG更为常见,Gyasi等对Emmanuel眼科诊所的455例POAG患者进行统计分析得出NTG仅有32例,约占POAG的7%。在国内关于临床上NTG和HTG比例的报道少见。如同血压一样,眼压同样具有复杂的变化与波动,容易受到各种内外在因素的影响,如年龄、体位、光照等,单次或少次的日间眼压测量不足以为确定POAG的类型提供充分的依据。在临床上POAG患者治疗前的眼压水平究竟如何,NTG占POAG的多大比例,而这个比例与中央角膜厚度、24小时眼压的变化等因素是否有关等问题尚待探讨,眼科流行病学研究与临床眼科学研究得到的NTG比例的差异给予我们怎样的启示有待思考。眼压与青光眼性视神经或视野损害的发生发展有着密切而复杂的联系。既往众多研究表明,病理性的眼压升高是发生青光眼视神经损害或视野损害的主要危险因素,局部降眼压药物可以有效的延缓或者阻止眼压升高的患者青光眼视神经损害的发生。眼压既是临床上确定治疗目标又是评价治疗效果的一个非常重要的指标。POAG患者确诊时的视野损害程度关系到疾病的治疗与进展。Ren等研究得出青光眼视野缺损与眼压之间存在正相关,相关系数为0.57。然而在确诊时POAG患者的眼压与视野损害程度之间具有怎样的关系,临床上POAG患者确诊时的视野损害情况如何,确诊时的视野损害严重程度还与哪些因素相关,国内相关报道少见。鉴于以上,我们对广州军区武汉总医院青光眼专家门诊就诊的POAG患者进行了一年多的临床观察,以了解临床上POAG患者治疗前的眼压水平及眼压与POAG患者确诊时视野损害程度的关系。本课题分为两个部分：第一部分通过对我院青光眼专家门诊就诊的POAG患者治疗前的眼压水平与24小时眼压的观察,了解临床上NTG和HTG的构成比及该比例与中央角膜厚度(central corneal thickness,CCT)、24小时眼压等因素的关系；第二部分通过对POAG患者确诊时的视野损害严重程度、眼压水平等因素的观察,了解我院POAG患者确诊时的视野损害状况及其与眼压等因素的关系。第一部分原发性开角型青光眼患者治疗前的眼压水平分析目的了解临床上原发性开角型青光眼患者治疗前的眼压水平,探讨临床上正常眼压性青光眼与高眼压性青光眼的构成比以及中央角膜厚度和24小时眼压对该构成比的影响。方法收集2014年5月至2015年4月于广州军区武汉总医院青光眼专家门诊就诊并符合纳入标准的POAG患者。分析其治疗前的随机眼压水平。分别依据患者用药前的门诊最大随机眼压值、CCT校正后的门诊最大随机眼压值和CCT校正后的24小时眼压峰值是否大于21mmHg,将患者分为HTG(眼压21mmHg)和NTG(眼压21mmHg)。比较不同的分类方法下,两种类型POAG患者的例数和构成比。不同年龄、不同性别的POAG患者的眼压水平采用独立样本t检验。不同分类方法下,两两之间的构成比比较采用x2检验。结果研究共纳入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,年龄(47.68±15.74)岁。以患者双眼中眼压较高眼的眼压值进行分析,POAG患者治疗前经CCT校正后的门诊最高随机眼压为：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%)。男性患者的眼压(32.34±13.49)mmHg高于女性患者的眼压(25.86±9.99)mmHg,40岁及以下患者的眼压(36.03±13.62)mmHg高于40岁以上患者的眼压(27.22±11.32) mmHg,差异均有统计学意义(P0.05)。分别以患者用药前的门诊最大随机眼压值、CCT校正后的门诊最大随机眼压值和CCT校正后的24小时眼压峰值进行分类,HTG和NTG的患者例数和构成比分别为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%)。依据门诊最大随机眼压值进行分类得到的NTG的构成比小于依据CCT校正后的门诊最大随机眼压值分类得到的NTG的构成比,但两者的差异无统计学意义(p0.05)。这两种分类标准得出的NTG和HTG的构成比分别与依据CCT校正后的24h眼压峰值进行分类得到的NTG和HTG的构成比相比差异均具有统计学意义,后一种分类标准得到的NTG比例显著较低(p0.05)。结论在我院青光眼专家门诊就诊的POAG患者中,依据不同的眼压标准进行分类得到的NTG的构成比不同,若以CCT校正后的24小时眼压峰值结果为判断标准,则NTG仅占POAG的极小部分。CCT可能不会影响总体的NTG比例,但会影响个体的POAG类型的判别。在POAG的诊断过程中,我们应重视对眼压动态全面系统的分析。第二部分原发性开角型青光眼患者确诊时视野损害程度的相关因素分析目的通过对原发性开角型青光眼患者确诊时的视野、眼压水平等因素的观察,了解我院原发性开角青光眼患者确诊时的视野损害状况及其相关因素。方法收集2014年5月至2015年10月在广州军区武汉总医院青光眼专家门诊就诊并符合纳入标准的POAG患者。观察患者确诊时的视野和眼压情况。以患者双眼中视野损害较严重的眼进行分析,根据确诊时的视野损害程度分级将患者分为早期视野损害组(视野损害0-1级)和中晚期视野损害组(视野损害2-5级)。对两组患者的确诊年龄、性别、身体质量指数(BMI)、青光眼相关症状、家族史、高度近视、CCT、眼压等相关因素进行统计分析。计量资料采用t检验；计数资料采用Z2检验,相关性分析采用Spearman双变量相关分析法。结果研究共纳入确诊为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%,年龄14～81(48.73±17.02)岁,确诊年龄为14～81(47.59±17.20)岁。早期视野损害组31例(27.43%),确诊年龄为(52.81±16.57)岁,其中男性19例(61.29%),女性12例(38.71%),BMI为(22.00±4.72)kg/m2,具有青光眼相关症状的有9例(29.03%),具有明确青光眼家族史的有3例(9.68%),合并高度近视的有3例(9.68%),CCT为(533.12±29.79)μm,IOP为(23.67μ11.44) mmHg。中晚期视野损害组82例(72.57%),确诊年龄为(45.62±17.12)岁,其中男性61例(74.39%),女性21例(25.61%),BMI为(23.24±3.08)kg/m2,具有青光眼相关症状的有44例(53.66%),具有明确青光眼家族史的有7例(8.54%),合并高度近视的有24例(29.27%),CCT为(536.93μ35.02)μm,IOP为(30.58μ12.13) mmHg。经SPSS统计软件统计分析后得出,早期损害组的眼压低于中晚期损害组,确诊时的年龄大于中晚期损害组,合并高度近视眼的患者比例小于中晚期损害组,具有青光眼相关症状的患者比例小于中晚期损害组,差异均有统计学意义(均为P0.05)；早期损害组的性别比例、BMI、青光眼家族史、CCT与中晚期损害组相比,差异均无统计学意义(均为P0.05)。眼压与POAG患者确诊时的视野损害严重程度间呈正相关(r=0.411,P=0.000)。结论在我院青光眼专家门诊就诊的POAG患者中,大多数患者在确诊时已经发生了较严重的视野损害,高眼压、具有青光眼相关症状、合并高度近视、确诊时的年龄偏低可能是POAG患者确诊时发生较严重视野损害的危险因素。
[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.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R775.2

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