1、晶状体病DISORDERS OF LENS哈尔滨医科大学第一临床医学院附属眼科医院EYE HOSPITAL OF THE 1ST CLINICAL MEDICAL COLLEGE, HMU,晶状体（lens)为双凸形状，有弹性，是无血管的透明组织，具有复杂的代谢过程。营养主要来自房水。它是眼屈光间质重要的组成成分。主要的病变是其透明度和位置的改变，都会严重影响视力。The lens is a kind of avascular transparent tissue with complex metabolic process. Its nourishment mainly comes from
2、 aquous humour. The disorder of the lens is commonly loss of its transparency and abnormality of its position; both can induce severe visual disturbance.,白内障 CATARACT,概述(Introduction)广义上讲晶体发生混浊就可称为白内障（cataract)，但只有对视力有影响时，才有临床意义。The opacity of lens is generally called cataract. But mild opacity of t
3、he lens has no affection to vision without any clinical significance.,病因（Etiology)：许多因素，如老化、遗传、代谢异常、外伤、辐射、中毒、局部营养障碍等，引起晶状体囊膜损伤，使其通透性增加和丧失屏障作用，或导致晶状体代谢紊乱，都可使晶状体蛋白质发生变性，造成混浊。,白内障的分类CLASSIFICATION OF CATARACT,1.按病因(according to etiology)：分外伤性(injuried)、并发性(complicated)、代谢性(metabolic)、中毒性(toxic)、辐射性(rad
4、iating)、发育性(develoing)和后发性(after-cataract)白内障。,2. 按发病年龄（according to age of occurring): 先天性（congenital）、婴儿性（ infantile）、 青少年性（juvenile）、成年性（adult）、老年性（senile）。3. 按混浊部位（according to the site of opacity): 皮质性（cortical）、核性（ nuclear）、囊膜下（subcapsular）、囊膜性（capsular）。,4. 按混浊的程度(according to the degree of o
5、pacity)：初期（incipient)、未熟期(immature)、成熟期(mature)、过熟期(hypermature)。5. 按混浊形态(according to the shape of opacity)：点状(punctate)、冠状(coronary)、板层白内障(lamellar)。,年龄相关性白内障（age-related cataract),是中老年开始发生的晶状体混浊，随着年龄增加，患病率明显增高。由于它主要发生于老年人中，又称老年性白内障。分为皮质性、核性和后囊下三种类型。is the most common one, often seen in the elder
6、more than 50 years old. With aging its morbidity rate goes higher. It is gradually appeared degenerative change in the course of lens aging. Its pathologic mechanism isnt understood completely yet, related with ultraviolet ray, with systemic disease such as diabetes, hypertension, arteriosclerosis,
7、genetic factor as well as lens nourishment and metabolic condition and so on.,临床表现（clinical findings),常双眼患病，但发病可有先后，严重程度也不一致。主要症状为眼前阴影和渐进性、无痛性视力减退。由于晶体吸收水分后体积增加，屈光力增强。因晶体纤维肿胀和断裂，使屈光度不均一，可出现单眼复视或多视。因光线通过部分混浊的晶状体时产生散射，干扰视网膜上成像，可出现畏光和眩光。,症状（symptoms)主要症状是视力模糊、减退、并可致盲。其视力障碍与晶体混浊的位置有关。自觉症状有以下3点：1.眼前出现固定不
8、动的黑点；2.单眼多视，物像变形或出现重影；3.晶体性近视的出现是由于晶体核硬化。,体征(signs),表现为各种类型的混浊，形态多样，完全混浊的晶体，白瞳症是最明显的体征，而在此之前受白内障种类及程度的影响，瞳孔区可呈现灰白色、淡黄、棕色等色调。,1. 皮质性白内障（cortical cataract): 最为常见。按其发展过程分为4期。It is the most common type of senile cataract, according to the development; it is divided into 4 stages.(1) 初期（incipient stage):
9、 晶体皮质内出现空泡、水裂和板层分离。空泡为圆形透明小泡，位于前后皮质中央部或晶状体缝附近。水裂的形态不一，从周边向中央逐渐扩大。板层分离多在皮质深层，呈羽毛状。楔形混浊常见。位于前后皮质，尖端向着晶体中心，基底位于赤道部。,Cuneiform opacity appears at the periphery of anterior and posterior cortex, its base is at the equator, its tip towards the center, often occurring at lower part, then similar opacity oc
10、curs at bilateral and upper parts, then forms wheel-like opaque. The pupillary area is not affected, commonly without blurred vision. The early phenomenon is separation of lens fibrous lamina like feather, sometimes vacuole appears.,(2) 未熟期（immature stage)：又称膨胀期(intumescent)。晶体混浊继续加重时，渗透压改变，在短期内有许多水
11、分积聚，晶体急剧肿胀，体积变大，将虹膜向前推移，前房变浅，可诱发急性闭角型青光眼。晶体呈不均匀的灰白色混浊，视力明显减低。The opacity gradually becomes obvious, the cortex absorbs water to swollen. Lens volume increases to push iris forward and the anterior chamber shallows, and may induce acute attack of glaucom.,(3).成熟期（mature stage)：晶体内水分和分解产物从囊膜逸出，晶体又恢复到原
12、来体积，前房深度恢复正常。晶体逐渐全部混浊。患眼视力降至眼前手动或光感。从初发期到成熟期可经10多个月至数十年不等。Lens became opaque totally, swelling of the lens diminished, the anterior chamber restored to normal. The fundus can not be seen, vision decreased to light perception or hand movement, but the light seeking and color sensation were in normal.
13、,(4).过熟期（hypermature stage): 如果成熟期持续时间过长，经数年后晶体内水分继续丢失，体积缩小，囊膜皱缩，出现不规则的白色斑点及胆固醇结晶，前房加深，虹膜震颤。晶体纤维分解液化，呈乳白色，棕黄色的晶体核沉于囊袋下方，可随体位变化而移动。称为Morgagnian白内障。当晶体核突然下沉后，视力可突然提高。过熟期白内障囊膜变性，通透性增加或出现细小的破裂。当液化的皮质漏出时，可发生晶体诱发的葡萄膜炎。长期存在于房水中的晶体皮质可沉积于房角，引起青光眼。称晶体溶解性青光眼。过熟期白内障的晶体悬韧带发生退行性变，容易发生晶体脱位。,The mature stage contin
14、ued for over long time, generally for several years,the water in the lens lost continuously, the volume of lens diminished, the capsular membrane shrank, the anterior chamber deepened with iridodonesis. Lens fibers decomposed and dissolved in cream-white liquefaction, brown-yellow hard nuclear sank
15、down, the anterior chamber in upper part became deep, called Morgagnian cataract. The nucleus may move with change of body position,vision may increased suddenly. Lens cortex leaked out of lens capsule may induce glaucoma. Severe vibration may make lens capsule rupture; lens mucleus dislocated into
16、the chamber or vitreous body to induce glaucoma. Lens ligament was often retrograde degeneration that was easy to bring about lens dislocation.,2. 核性白内障（nuclear cataract)较皮质性白内障少见，发病年龄较早，进展缓慢。混浊开始于胎儿核或成人核，前者多见，逐渐发展到成人核完全混浊。初期晶体核呈黄色混浊，但很难与核硬化相鉴别。散瞳检查，在周边部环状红色反光中，中央有一暗影，眼底检查可由周边部看清。由于屈光力增加，可发生近视。可发生单眼
17、复视或多视。核性白内障以后逐渐变为棕黄色或棕黑色。此时视力极度减退，眼底已看不清。,3. 后囊下白内障（subcapsular cataract)后囊下浅层皮质出现棕黄色混浊，为许多致密小点组成，其中有小空泡和结晶样颗粒，外观似锅巴状。由于混浊位于视轴，所以早期出现明显视力障碍。It is a manifestation of cortical cataract, may happen beneath the anterior or posterior capsule. In posterior subcapsular cataract, there is disciform opaque b
18、eneath the posterior at early stage, composed of many dense punctates, with vacuoles and crystalloid granules among them, similar to the surface of slag brick called disciform cataract too. Subcapsular cataract may develop and form total cortical cataract.,诊断（DIAGNOSIS）,散瞳后，以裂隙灯检查。根据晶体混浊的形态和视力情况可明确诊
19、断。当视力减退与视力情况不符合时，应进一步检查，避免因晶体混浊而漏诊其他眼病。,治疗（TREATMENT）,目前药物治疗尚无肯定疗效，因白内障影响生活和工作时，可考虑手术治疗。At present, there is not any effective drug, so cataract can take operation for treatment.手术时机：以往认为最佳手术时机是白内障完全成熟时。目前因手术技术的进步，当视力低于0.3（或0.5），影响工作和生活时即可考虑手术,术前检查（pre-operation examination)(1) 全身检查（systemic ）：包括血压（
20、blood pressure)、血糖(blood sugar)、心电图(electrocardiogram, ECG)、胸片(chest X-ray)、肝功(liver function)等。血糖应控制在8.3mmlo/L。(2) 眼部检查（ocular ): 视力(visual acuity)、光定位（light preception)、眼压(IOP)、角膜内皮(endothelium)、角膜曲率(corneal curvature)、IOL度数测算等。,手术方法（operative method)(1) 白内障囊外摘出术及后房型人工晶体植入是最佳手术方案。extracapsular cataract extraction (ECCE) and posterior chamber lens implantation is the best operating method.(2) 白内障囊内摘出术，整个晶体连同囊膜一起摘出。并发症较多。Intracapsular cataract extraction, the complications such as vitreous prolapse, retinal detachment are more than ECCE.,
