【作者】 张睿；

【导师】 叶存喜；

【作者基本信息】 河北医科大学 ， 眼科学， 2012， 硕士

【摘要】 睫状环阻滞性青光眼又称作恶性青光眼，这一经典概念由德国医师Von Graefe在1869年首次提出，是一种多因素、多机制的继发性闭角型青光眼，在有或没有异常眼部解剖结构的基础上，这些因素或发病机制共同参与睫状环阻滞和房水迷流，导致房水聚焦于玻璃体内并推挤晶状体-虹膜隔向前移位，当发病时同时或部分具有下列特征：(1)前房普遍性（中央和周边）变浅或消失；(2)眼压升高或正常；(3)缩瞳剂治疗无效或使病情恶化；(4)局部使用散瞳睫状肌麻痹剂治疗有效；(5)对特殊的玻璃体手术治疗反应尚可；(6)无瞳孔阻滞。在疾病发作前期，睫状环阻滞性青光眼的患眼具有“逆药现象”，点用缩瞳剂后前房变得更浅且眼压反而更高。但由于多种抗青光眼药物的联合应用，眼压逆药性升高这一特点往往可以被掩盖，因此临床上对于可疑睫状环阻滞性青光眼的患者，点用缩瞳剂后，密切关注其前房深度对药物的变化反应，对于疾病的早期临床诊断有很大帮助，使我们可以在该疾病早期给予相对简单的干预措施，从而达到早期治疗疾病的目的。Oculus-Pentacam三维前房分析仪由德国Oculus公司生产，为世界首款利用旋转Scheimflug技术的摄像机，配置有两个整合摄像机：第一个位于中心，负责瞳孔大小和位置的监测，控制定位，同时监视眼球运动情况并根据其对眼球内部进行校正；第二个位于旋转轮上，通过旋转摄像，来获取眼前段图像，它从0o到180o角度在适于2秒的时间内50次拍摄裂隙图像，并且每张照片可获取500个真实高度点，通过编辑，最终可以获得每个层面25000个真实高度点，获得真实眼前段360o三维结构图像。其特点为多角度、三维立体，且具有在三维立体条件下实现动态重现的功能，以彩图的方式显示角膜、前房和晶状体的各种参数测量结果。Oculus-Pentacam三维前房分析仪目前主要应用于测量角膜厚度、测量角膜地形图、分析白内障、对眼前段结构进行成像并分析前房。在对前房的分析中，可以对前房角、前房容积、前房深度、瞳孔直径等参数进行测量，并以彩图的方式显示前房结构。与其他的检查设备相比，Oculus-Pentacam三维前房分析仪具有完全非接触性，图像分辨率高，图像易于解释和测量等优点，并且独具其三维立体、动态重现的特点。其操作测量方式简单，易于被患者接受，可重复性好，用于客观记录前房动态变化比较明显的优势。Oculus-Pentacam三维前房分析仪可以为闭角型青光眼的筛查、诊断以及治疗效果评估方面提供临床依据。目的：报道一病例利用Oculus-Pentacam三维前房分析仪对睫状环阻滞性青光眼作出临床诊断，研究睫状环阻滞性青光眼发病早期特殊的临床表现，探讨临床上Oculus-Pentacam三维前房分析仪对于睫状环阻滞青光眼早期诊断的价值。方法：一名主诉双眼胀痛、视物不清，伴头晕、恶心、呕吐的青年女性患者，滴用毛果芸香碱治疗后出现浅前房，高眼压，验光发现存在高度近视，其双眼轴短小，疑似诱发睫状环阻滞性青光眼。通过结合相关文献，分析疾病早期临床特征，利用Oculus-Pentacam三维前房分析仪测量其缩瞳前后前房形态参数变化，对结果进行分析比较。结果：点用缩瞳剂前Oculus-Pentacam三维前房分析仪测量结果：右眼瞳孔直径3.56mm，前房轴深3.38mm，前房容积245mm3，房角41.9°，左眼瞳孔直径2.91mm，前房轴深3.51mm，前房容积235mm3，房角43.5°；点用缩瞳剂后Oculus-Pentacam三维前房分析仪测量结果：右眼瞳孔直径1.42mm，前房轴深2.39mm，前房容积103mm3，房角34.5°，左眼瞳孔直径1.43mm，前房轴深2.29mm，前房容积106mm3，房角33.1°。缩瞳剂使用前后双眼前房结构发生明显变化:前房轴深右眼变浅0.99mm，左眼变浅1.22mm；前房容积右眼变小132mm3，左眼变小129mm3；前房角右眼变小7.4o，左眼变小10.4o。患者停用缩瞳剂，前房加深，临床症状缓解，视力提高，没有使用散瞳剂，随访2个月，病情稳定无复发。结论： Oculus-Pentacam三维前房分析仪可以客观准确地记录前房的动态变化，对于早期可疑睫状环阻滞性青光眼的临床辅助诊断是理想的选择。更多还原

【Abstract】 Ciliary block glaucoma is also known as the term malignantglaucoma,which was first proposed by Von Graefe,a German physician,in1896.It is a secondary angle closure glaucoma ofmulti-factor,multi-mechanism.With or without abnormal ocular anatomicalstructures,those factors or mechanisms participated in the process of ciliaryblock and aqueous misdirection,so that aqueous humor accumulated in thevitreous and the lens-iris diaphragm was pushed forward. Numerous clinicalentities share all or some of the following findings:(1)shallowing of anteriorchamber(central and periphery);(2)increased or normal intraocularpressure(IOP);(3) no effect or worsening following miotic therapy;(4)improvement with mydriatic-cycloplegic therapy;(5)response to specialvitreous surgery;(6) absence of pupillary block.At early stage of the process,aconverse effect with miotic therapy could be seen in suffered eyes,which is themore shallow anterior chamber and higher IOP.However,the higher IOP couldnot be obvious because of the combination of the variety of anti-glaucomadrugs.If we could monitor the change of anterior chamber depth closely aftertreatment of miotic,then there mey be an early diagnosis,which could result inan early treatment of this disease.The Oculus-Pentacam three-dimensional anterior chamber analyzer wasproduced by the German company Oculus.It is the world’s first instrument touse a rotating Scheimflug camera, configured with two integratedcameras.One is located centrally, monitoring the condition of pupil, fixingposition,monitoring and correcting for eye movement and reports on thequality of each measurement.The another one locates on the rotatingwheel,which can take images of the anterior segment by rotating.Within2seconds,it can take50images from0o to180o,each of which will have500ture elevation points.By editing,there will be25000true elevation points of everytangential and sagittal(axial) curvature.In that case,a true360othree-dimensional structural image of the anterior segment will present.Thisinstrument has the characters of multi-angle, three-dimensionalvisualization,animation of the anterior segment and a coulorful pictureshowing the measurements of various parameters of cornea,anterior chamberand lens.The Pentacam is mainly used in measurement of cornealthickness,measurement of corneal topography,analysis of cataract,anteriorsegment imaging and analysis of anterior chamber.When it is used in analysisanterior chamber,the parameters of anterior chamber angle,anterior chambervolume,anterior chamber depth, pupil diameter and so on will bemeasured.Copared with other instruments,the Pentacam is non-contact forpatients,and provides a high resolution picture which can be easy to interpretand measure.And the most important is three-dimension and animation.It hasan easy operation and good repeatability and can be accepted easily bypatients,so that is an advantage for an objective record of dynamic change ofthe anterior chamber.The Pentacam can provide clinical evidences for thescreening,diagnosis and assessment of treatment of angle-closure glaucoma.Purpose: Reporting a case in which the clinical diagnosis of ciliary blockglaucoma was made by the Pentacam,to study the particular clinicalmanifestation at the early stage of this disease and discuss the value of thePentacam for clinical diagnosis of ciliary block glaucoma.Method: A young female patient came for treatment with chief complaintof gas pains and blurry vision of both eyes,accompany with dizziness,nauseaand vomiting.Shallow anterior chamber and high IOP presented when shereceived routine anti-glaucoma treatment including miotic therapy.Result ofoptometry showed she was highly myopia,but whose axial length wasshort.Then ciliary block glaucoma was suspected.By analyzing past casespublished,we found some clinical feature of early stage.We used the Pentacamto measure the parameters of anterior chamber prior to and after instillation ofmiotic,and the results were analyzed. Result:Measurements of anterior chamber prior to instillation were:righteye,pupil diameter(PD)3.56mm,anterior chamber depth(ACD)3.38mm,anterior chamber volume(ACV)245mm3,anterior chamberangle(ACA)41.9°,and left eye,PD2.91mm，ACD3.51mm，ACV235mm3，ACA43.5°.After instillation,the results were:right eye,1.42mm,ACD2.39mm,ACV103mm3,ACA34.5°,and left eye,PD1.43mm,ACD2.29mm,ACV106mm3,ACA33.1°.As the effect of miotic instillation,parameters of anterior chamber changed obviously.ACD decresed0.99mm in right eye and1.22mm in left eye.ACV decreased132mm3rightand129mm3left.ACA decreased7.4o right and10.4o left.As the miotic wasdiscontinued,anterior chamber deepened and visual acuity improved.For the2-month follow up without mydriatic therapy,condition was stable,withoutrecurrence.Conclusion: The Pentacam,which can be used to record the dynamicchange of anterior chamber objectively and accurately,may be a good choicefor the early clinical diagnosis of suspected ciliary block glaucoma.更多还原