1、,Glaucoma,GOALS,确定视神经结构、功能,评估发展成POAG的风险,确定处理方案,减少副作用,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,确定视神经结构、功能,评估发展成POAG的风险,确定处理方案,减少副作用,健康教育,Identify patients at high risk of developing POAG,GOALS,
2、确定视神经结构、功能,评估发展成POAG的风险,确定处理方案,减少副作用,健康教育,Consider treatment of high-risk individuals to prevent or delay the development of POAG,GOALS,确定视神经结构、功能,评估发展成POAG的风险,确定处理方案,减少副作用,健康教育,Minimize the side effects of treatment and the impact of treatment on the patients vision, general health, and quality of
3、life,GOALS,确定视神经结构、功能,评估发展成POAG的风险,确定处理方案,减少副作用,健康教育,Educate 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 preserve patients quality of
4、life.,避免视神经损害避免发展成POAG,维持患者生活质量,DISEASE DEFINITION,A glaucoma suspect is an individual with clinical findings and/or a constellation of risk factors that indicate an increased likelihood of developing POAG.,clinical findings,The that define a glaucoma suspect patient are characterized by one of the
5、following in at least one eye in an individual with open anterior chamber angles by gonioscopy:,Appearance of the 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 he
6、morrhage Nerve fiber layer defect,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 standard deviation,Consistently elevated intraocular pressure (
7、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 secondary causes for open-angle glaucoma, such as pseudoexfoliation (exfoliation syndrome), pigment dispersion, and traumatic angle recessio
8、n.,clinical findings 小结,one of the following in at least one eye in an individual 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 neuropa
9、thies 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 IOPThe public health importance of early detection and management of these patient
10、s lies in the fact that individuals with ocular hypertension are at increased risk of developing glaucomatous optic neuropathy. The Ocular 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
11、years, or approximately 2% per year.,a constellation of 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 standard deviation on threshold visua
12、l 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 such a relationship. The preponderance of the evidence suggests that type 2 diabetes mellitus is associated with
13、 a higher prevalence of open-angle glaucoma.,migraine headache, peripheral vasospasm, concurrent cardiovascular disease, systemic hypertension, and myopia. However, the association between these risk factors and the development of glaucomatous optic nerve damage has not been demonstrated consistentl
14、y.,While disc hemorrhage, 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 unsuspected glaucoma.,CARE PROCESS,DIAGNOSIS,The comprehensive in
15、itial glaucoma suspect evaluation (history and physical examination) includes all components of the comprehensive adult medical eye evaluation51 in addition to and with special attention to those factors that specifically bear upon the diagnosis, course, and treatment of POAG. The evaluation may req
16、uire more than one visit. For instance, an individual might be suspected of having 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 he
17、ad and retinal nerve fiber layer evaluation and documentation.,Ophthalmic Evaluation,成人眼部综合评估+下列需要特别关注的眼部评估:病史 视力检查瞳孔检查 前节检查眼底检查眼压测量前房角镜检查 视盘和视网膜神经纤维层检查,病史,眼部病史、家族史（尤其青光眼病史）、系统性疾病史（哮喘、偏头痛、血管痉挛）。回顾相关记录,尤其关注眼压和视神经、视野状态 眼部和全身药物治疗 (糖皮质激素) 以及局部或全身对药物的敏感性（known local or systemic intolerance to ocular or s
18、ystemic medications） 眼部手术：角膜屈光手术非常重要（角膜厚度下降，眼压值偏低）。白内障手术后眼压偏低。,视力检查,远视力：裸眼视力和矫正视力(矫正度数)近视力：必要时,瞳孔检查,传入性瞳孔障碍,眼前节检查,裂隙灯检查：窄房角（周边浅前房和前房角拥挤）角膜病变继发眼压升高的因素：剥脱综合症、色素播散、虹膜透照缺损、虹膜和房角新生血管、炎症,眼压检查,检查方法：NCT、修氏眼压、压平眼压计在做其他检查前先测眼压：尤其前房角镜和散瞳检查记录眼压检查具体时间：评估眼压的日间变异24小时眼压测量评估眼压的波动,前房角镜检查,排除以下因素：房角关闭继发性原因造成眼压升高房角后退色素d
19、ispersion周边房角粘连房角新生血管炎症沉着物 www.gonioscopy.org,视盘和RNFL检查,重要性：视盘改变、RNFL改变和视盘周围的脉络膜萎缩早于视野缺损。视盘出血是重要的体征。裂隙灯：散瞳下放大的立体像观察直接检眼镜：作为补充，由于放大倍率更大，可以提供更多的细节。无赤光照明用于RNFL,眼底检查,散瞳下的眼底检查寻找可引起类似视盘和视野改变的眼底病变视神经苍白视盘玻璃疣视盘小凹 optic nerve pits中枢神经系统疾病造成的视盘水肿黄斑变性视网膜血管阻塞,Supplemental Ophthalmic Testing,中央角膜厚度视野视盘和视网膜神经纤维层分析
20、,中央角膜厚度,CCT和IOP之间相关性：没有公认的校正公式CCT是一个独立于IOP的危险因素（OHTS level II ）,视野检查,自动静态视野检查The frequency doubling technology (FDT) method with the central 20-degree test program (C-20) short-wavelength automated perimetry (SWAP) with the central 24-degree test program (24-2) are two of several alternative testing
21、 methods to screen for a defect before conducting more definitive threshold testing比传统的白-白视野检查,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 available.
22、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 defects were not confirmed upon subsequent testing.110 It is best to use a consistent
23、examination strategy for visual field testing.,视盘和视神经纤维层分析,Color stereophotographycomputer-based imagingconfocal scanning laser ophthalmoscopyoptical coherence tomographyscanning laser polarimetry,MANAGEMENT,对于青光眼或疑似患者，眼压是唯一可调控因素 决定开始降眼压治疗是一个复杂的过程：眼科医生对检查结果的判断风险评估患者的评估患者的选择与患者（家属）探讨：危险因素的数量和严重程度，预后、
24、诊疗计划、治疗一旦开始就要长期坚持恰当的治疗方案：降眼压效果、副作用、依从性,何时开始治疗？,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 should be treated as described in the Pr
25、imary 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 with disc and retinal nerve fiber layer photography and computerized imaging of the optic nerve and nerve fiber layer.81,
26、120,A new visual field defect that is consistent with a pattern of glaucomatous visual field defect, 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 t
27、reatment.,In some 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 strong family history of glaucoma, borderline visual field test f
28、indings, African American heritage, high myopia, or pseudoexfoliation (exfoliation syndrome). Whatever the scenario, a discussion must occur between the physician and patient to outline the risks and benefits of treatment versus nontreatment.,目标眼压,目标眼压：20%基线眼压基线眼压？,治疗的选择,首选：药物治疗考虑因素：费用、副作用、用法首选：前列腺素衍生物、-受体阻滞剂用法：单眼治疗法、多次基线测量,随访,病史：随访期间眼部病史随访期间全身疾病和治疗史如果有进行药物治疗，要注意药物的副作用、药物使用情况、最后一次用药的时间,随访,眼部检查：视力裂隙灯眼压视盘、RNFL和视野检查的间隔受一下因素决定：较高的眼压、较薄的角膜、视盘出血、大的杯盘比、大的PSD、青光眼家族史,
