一、青光眼病因病理
青光眼(yan)(yan)(yan)(yan)按其病因可分為(wei)原發性(xing)青光眼(yan)(yan)(yan)(yan)和繼(ji)發性(xing)青光眼(yan)(yan)(yan)(yan)兩大(da)類。原發性(xing)青光眼(yan)(yan)(yan)(yan)患(huan)者一般(ban)存(cun)在解(jie)剖(pou)因素(su)，如(ru)眼(yan)(yan)(yan)(yan)球小、眼(yan)(yan)(yan)(yan)軸短、遠視、前房(fang)淺等。若(ruo)情緒波動、在光線較暗的地方停留過(guo)久(jiu)、長時間(jian)低頭閱(yue)讀(du)等，就可能誘發青光眼(yan)(yan)(yan)(yan)。嚴(yan)重者可導致(zhi)急性(xing)大(da)發作，如(ru)果(guo)治療(liao)不及時，可導致(zhi)性(xing)失明。繼(ji)發生青光眼(yan)(yan)(yan)(yan)多由于(yu)外傷、炎癥、出(chu)血、腫(zhong)瘤(liu)等，破壞了房(fang)角的結構，使房(fang)水排出(chu)受阻而(er)導致(zhi)眼(yan)(yan)(yan)(yan)壓升高。總之(zhi)，青光眼(yan)(yan)(yan)(yan)是由于(yu)眼(yan)(yan)(yan)(yan)內生成(cheng)的水不能正常排出(chu)而(er)引起的。
二、什(shen)么是青(qing)光眼
1、青(qing)(qing)光眼(yan)是指(zhi)眼(yan)內(nei)壓(ya)力(li)或(huo)(huo)間(jian)斷(duan)或(huo)(huo)持(chi)續升高(gao)的一種(zhong)眼(yan)病(bing)(bing)。眼(yan)內(nei)壓(ya)力(li)升高(gao)可(ke)因(yin)其病(bing)(bing)因(yin)的不(bu)(bu)(bu)同而有各種(zhong)不(bu)(bu)(bu)同的癥(zheng)狀(zhuang)表現。持(chi)續的高(gao)眼(yan)壓(ya)可(ke)給眼(yan)球各部(bu)分組織和視功能帶來損害(hai)，造(zao)成視力(li)下(xia)降和視野(ye)縮小。如不(bu)(bu)(bu)及時治療，視野(ye)可(ke)全部(bu)喪失(shi)(shi)甚至失(shi)(shi)明。故青(qing)(qing)光眼(yan)是致(zhi)盲的主要病(bing)(bing)種(zhong)之一。
2、繼發性青(qing)光眼是一(yi)些眼部(bu)疾病和某些全身病在眼部(bu)出現的合并癥，這類青(qing)光眼種類繁多(duo)，臨床(chuang)表現又各有其(qi)特(te)點，治療原則亦不盡相同，預后(hou)也有很大差異(yi)。
三、青(qing)光眼診斷檢查
青光眼(yan)病(bing)(bing)人的(de)診斷與其他疾病(bing)(bing)一樣，根據病(bing)(bing)史、臨(lin)床表現及檢(jian)查結果進行(xing)綜合分(fen)析。
1、對可疑患者(zhe)，首先應測量眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)。眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)大(da)于3.20kPa(24mmHg)為(wei)(wei)病(bing)理(li)性(xing)高眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)，但一(yi)(yi)(yi)次眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)偏高不(bu)能(neng)診斷青(qing)(qing)光(guang)眼(yan)(yan)(yan)(yan)(yan)(yan)，而一(yi)(yi)(yi)次眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)正常(chang)也不(bu)能(neng)排(pai)除青(qing)(qing)光(guang)眼(yan)(yan)(yan)(yan)(yan)(yan)。因為(wei)(wei)眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)在一(yi)(yi)(yi)日(ri)內呈周期性(xing)波動(dong)(dong)。日(ri)眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)波動(dong)(dong)大(da)于1.07kPa(8mmHg)為(wei)(wei)病(bing)理(li)性(xing)眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)。正常(chang)人雙(shuang)眼(yan)(yan)(yan)(yan)(yan)(yan)眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)接近，如雙(shuang)眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)差大(da)于0.67kPa(5mmHg)也為(wei)(wei)病(bing)理(li)性(xing)眼(yan)(yan)(yan)(yan)(yan)(yan)壓(ya)(ya)。其(qi)次應檢查(cha)眼(yan)(yan)(yan)(yan)(yan)(yan)底(di)，觀察視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)改(gai)變(bian)(bian)，青(qing)(qing)光(guang)眼(yan)(yan)(yan)(yan)(yan)(yan)的(de)(de)視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)改(gai)變(bian)(bian)具有一(yi)(yi)(yi)定的(de)(de)特殊性(xing)，有重要的(de)(de)臨床價值。常(chang)表(biao)現(xian)(xian)為(wei)(wei)病(bing)理(li)性(xing)陷(xian)(xian)凹(ao)，目前普遍采用陷(xian)(xian)凹(ao)與視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)直徑的(de)(de)比值(C/D)表(biao)示陷(xian)(xian)凹(ao)大(da)小。C/D大(da)于0.6或雙(shuang)眼(yan)(yan)(yan)(yan)(yan)(yan)C/D差大(da)于0.2為(wei)(wei)異常(chang);視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)沿變(bian)(bian)薄，常(chang)伴有視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)沿的(de)(de)寬窄不(bu)均和(he)切(qie)跡，表(biao)示視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)沿視(shi)(shi)(shi)(shi)神(shen)(shen)經(jing)纖(xian)維數(shu)量減少;視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)血(xue)(xue)(xue)(xue)管改(gai)變(bian)(bian)，表(biao)現(xian)(xian)為(wei)(wei)視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)邊(bian)緣出血(xue)(xue)(xue)(xue)，血(xue)(xue)(xue)(xue)管架空，視(shi)(shi)(shi)(shi)盤(pan)(pan)(pan)(pan)血(xue)(xue)(xue)(xue)管鼻側移(yi)位和(he)視(shi)(shi)(shi)(shi)網(wang)膜(mo)中央動(dong)(dong)脈(mo)搏(bo)動(dong)(dong)。此外(wai)，眼(yan)(yan)(yan)(yan)(yan)(yan)底(di)檢查(cha)可觀察視(shi)(shi)(shi)(shi)網(wang)膜(mo)神(shen)(shen)經(jing)纖(xian)維層缺損，由于它(ta)可出現(xian)(xian)在視(shi)(shi)(shi)(shi)野缺損前，被(bei)認(ren)為(wei)(wei)是(shi)青(qing)(qing)光(guang)眼(yan)(yan)(yan)(yan)(yan)(yan)早期診斷指征之一(yi)(yi)(yi)。
2、視(shi)野(ye)檢(jian)查對青光(guang)眼的診斷有重要(yao)價(jia)值。因為它代表了視(shi)神經(jing)的損傷(shang)。臨(lin)床常見視(shi)野(ye)缺損類型有：視(shi)閾值普遍降低(di)、弓形(xing)缺損、鼻側階梯、垂(chui)直階梯、顳側扇形(xing)缺損、中心及顳側島狀(zhuang)視(shi)野(ye)。
通過上述(shu)檢查，我(wo)們可(ke)以診斷(duan)青(qing)光眼(yan)(yan)(yan)(yan)，但在開始治(zhi)療前(qian)還應確定青(qing)光眼(yan)(yan)(yan)(yan)的類型。首先檢查前(qian)房角，房角開放(fang)者為開角型青(qing)光眼(yan)(yan)(yan)(yan)，反(fan)之則(ze)為閉角型青(qing)光眼(yan)(yan)(yan)(yan)。通過房角檢查，青(qing)光眼(yan)(yan)(yan)(yan)分類診斷(duan)仍有困(kun)難(nan)時，可(ke)查房水流暢(chang)系數(C值)。C值小于0.1為病理性(xing)，壓暢(chang)比(Po/C)大于150為病理性(xing)，主要見(jian)于開角型青(qing)光眼(yan)(yan)(yan)(yan)。但需注(zhu)意(yi)，閉角型青(qing)光眼(yan)(yan)(yan)(yan)反(fan)復發作后C值及壓暢(chang)比也可(ke)異常。另外我(wo)們對一些疑似青(qing)光眼(yan)(yan)(yan)(yan)可(ke)選一些激發試驗，以輔(fu)助診斷(duan)。
四、青光(guang)眼治療方法(fa)
青光眼治療的(de)(de)方法是降(jiang)低或(huo)控(kong)制眼壓，促使房水排出，因此根據青光眼的(de)(de)病因病機，可選擇藥(yao)物或(huo)手術治療。
1、原(yuan)發性開角型青光眼(yan)藥(yao)物治療(liao)，先用(yong)β受(shou)體阻滯劑抑制房(fang)水生成，如(ru)(ru)0.5%噻嗎心(xin)安、0.25%貝(bei)特舒等;眼(yan)壓(ya)控(kong)制不(bu)(bu)滿(man)意(yi)加(jia)(jia)用(yong)縮瞳劑，如(ru)(ru)1%匹(pi)羅卡(ka)品(pin)等，使(shi)小(xiao)梁網間隙增(zeng)寬，促進(jin)房(fang)水排出(chu);通過單用(yong)和(he)聯(lian)用(yong)兩(liang)類(lei)藥(yao)品(pin)仍不(bu)(bu)能(neng)控(kong)制眼(yan)壓(ya)或不(bu)(bu)能(neng)耐受(shou)者，可(ke)選用(yong)1%腎上腺(xian)素，該藥(yao)也能(neng)增(zeng)加(jia)(jia)房(fang)水排出(chu)。藥(yao)物治療(liao)無效或效果不(bu)(bu)滿(man)意(yi)，宜(yi)采(cai)用(yong)激光小(xiao)梁成形術(shu)(shu)，術(shu)(shu)后常需輔用(yong)藥(yao)物治療(liao)。
2、通過上述治療(liao)眼(yan)壓控制仍不理想，只能選用手術治療(liao)，常(chang)用手術是小梁切除術或其他(ta)濾過手術。術前眼(yan)壓較高者(zhe)可(ke)口(kou)服(fu)醋(cu)氮酰胺，口(kou)服(fu)甘(gan)油或和靜注20%甘(gan)露醇，盡可(ke)能使眼(yan)壓降至正(zheng)常(chang)。術后用5-Fu等抗(kang)代謝藥球結膜下注射，減少(shao)術后濾枕疤痕形成。
3、原發性閉角型青光(guang)眼一經(jing)確(que)診，手(shou)術(shu)治(zhi)療(liao)，藥(yao)物治(zhi)療(liao)只限于為手(shou)術(shu)作準備(bei)及手(shou)術(shu)后眼壓(ya)控制不良或手(shou)術(shu)危(wei)險很大等(deng)情(qing)況(kuang)下。現在由于許多(duo)醫院能(neng)作激光(guang)周邊虹膜(mo)打孔，使絕大多(duo)數患者免除了根切(qie)手(shou)術(shu)，但如不具備(bei)條件，還是應盡早作虹膜(mo)根切(qie)術(shu)。
4、急性(xing)發作(zuo)期患者眼(yan)壓(ya)(ya)(ya)高，應(ying)先用藥(yao)物降眼(yan)壓(ya)(ya)(ya)，20%甘(gan)露醇靜滴(di)，必(bi)要時(shi)可用1%匹羅(luo)卡(ka)品和噻嗎心安點眼(yan)，或加用醋氮酰胺口(kou)服。有(you)條(tiao)件時(shi)可作(zuo)激(ji)光(guang)周(zhou)(zhou)邊(bian)虹(hong)(hong)膜打孔，激(ji)光(guang)周(zhou)(zhou)邊(bian)虹(hong)(hong)膜成形(xing)或激(ji)光(guang)瞳孔成形(xing)，解除瞳孔阻滯。術(shu)前務(wu)必(bi)使眼(yan)壓(ya)(ya)(ya)降至正常，眼(yan)壓(ya)(ya)(ya)控(kong)制后(hou)，檢查房角，如50%以(yi)上(shang)房角開放，仍可選擇虹(hong)(hong)膜根切(qie)(qie)術(shu)，否則應(ying)選擇小(xiao)梁切(qie)(qie)除術(shu)等(deng)濾過(guo)手術(shu)。術(shu)后(hou)眼(yan)壓(ya)(ya)(ya)控(kong)制不(bu)良(liang)應(ying)輔用藥(yao)物。
5、先天性青光眼宜盡早手(shou)術(shu)(shu)(shu)。常用(yong)手(shou)術(shu)(shu)(shu)有(you)房角(jiao)切(qie)開術(shu)(shu)(shu)，小(xiao)梁切(qie)開術(shu)(shu)(shu)和小(xiao)梁切(qie)除術(shu)(shu)(shu)，也(ye)可(ke)二者聯用(yong)。術(shu)(shu)(shu)前、術(shu)(shu)(shu)后可(ke)輔用(yong)藥物控制(zhi)眼壓，常用(yong)噻(sai)嗎心安，避用(yong)縮瞳(tong)劑。
6、繼(ji)發性(xing)青光(guang)(guang)(guang)眼(yan)(yan)(yan)種類很(hen)多，治(zhi)療上差異較(jiao)大(da)。原則是原發病與青光(guang)(guang)(guang)眼(yan)(yan)(yan)同(tong)(tong)時(shi)治(zhi)療，繼(ji)發性(xing)開角型青光(guang)(guang)(guang)眼(yan)(yan)(yan)的治(zhi)療大(da)致同(tong)(tong)原發性(xing)開角型青光(guang)(guang)(guang)眼(yan)(yan)(yan)，惡性(xing)青光(guang)(guang)(guang)眼(yan)(yan)(yan)的處理(li)需(xu)特(te)別謹慎，新生血管性(xing)青光(guang)(guang)(guang)眼(yan)(yan)(yan)條件許可時(shi)全視網(wang)膜光(guang)(guang)(guang)凝術。晚(wan)期(qi)青光(guang)(guang)(guang)眼(yan)(yan)(yan)喪失(shi)視功能，有(you)嚴(yan)重(zhong)疼(teng)痛，大(da)泡性(xing)角膜炎時(shi)，可選擇睫狀體冷凍(dong)或眼(yan)(yan)(yan)球摘除(chu)。
五、青光眼癥狀
青光(guang)眼(yan)的癥狀是(shi)由于眼(yan)壓(ya)升高、視(shi)神經功能障礙引(yin)起。如閉角(jiao)性青光(guang)眼(yan)發作(zuo)前常有生氣(qi)、勞(lao)累等(deng)誘因，引(yin)起眼(yan)壓(ya)急驟升高，出現(xian)虹視(shi)、眼(yan)痛(tong)(tong)、頭痛(tong)(tong)惡心嘔吐(tu)、視(shi)力下降、眼(yan)充血和流淚等(deng)癥狀。
早期輕微(wei)的(de)發(fa)作，到明(ming)亮處(chu)引起(qi)縮瞳，即可自行緩(huan)解。而開角(jiao)性(xing)青(qing)光眼(yan)(yan)的(de)自覺癥(zheng)狀(zhuang)一般輕微(wei)，有(you)時沒有(you)癥(zheng)狀(zhuang)。眼(yan)(yan)壓升高極為緩(huan)慢，即便(bian)眼(yan)(yan)壓升高，也無角(jiao)膜水腫和(he)疼痛(tong)，但視力逐(zhu)漸(jian)下降，常(chang)常(chang)發(fa)生視神經的(de)損(sun)害。
(1)急(ji)性閉角青(qing)光眼(yan)：病(bing)(bing)人(ren)(ren)急(ji)性期主要癥狀是感(gan)覺劇烈眼(yan)痛及(ji)同(tong)側頭痛、虹視(shi)、視(shi)象、嚴重者僅留眼(yan)前(qian)指(zhi)數或光感(gan)，常合并惡心、嘔吐、發熱、寒戰(zhan)及(ji)便秘等(deng)，少數病(bing)(bing)人(ren)(ren)可有腹瀉發生(sheng)。檢查時(shi)，可發現眼(yan)壓高、瞳孔散大(da)、眼(yan)部(bu)充血、角膜(mo)水腫、房水混濁、晶(jing)體改變、前(qian)房變淺(qian)、房角閉塞(sai)、虹膜(mo)萎縮等(deng)。
(2)慢性(xing)閉角(jiao)青光眼(yan)(yan)病人主要癥狀是或(huo)多或(huo)少(shao)眼(yan)(yan)部不適，發作性(xing)視蒙(meng)、虹(hong)視，這種發作冬季常見，多在傍(bang)晚或(huo)午后(hou)出現，充分睡眠(mian)休息后(hou)眼(yan)(yan)壓正(zheng)常，癥狀消失，少(shao)數(shu)人無任(ren)何(he)不適，偶爾(er)遮蓋健眼(yan)(yan)發現患眼(yan)(yan)視力下降甚(shen)至失明。檢查時有陽(yang)性(xing)發現
(3)開角(jiao)青光眼(yan)主(zhu)(zhu)要(yao)特(te)點是(shi)高(gao)眼(yan)壓下前房角(jiao)寬而開放，主(zhu)(zhu)要(yao)癥(zheng)狀是(shi)頭昏、頭痛(tong)、眼(yan)脹或視蒙。眼(yan)壓初期不(bu)穩定(ding)，以(yi)后漸增(zeng)高(gao)。眼(yan)底(di)、視野均(jun)有改變
(4)先天(tian)性(xing)青光(guang)眼是一種胚胎期前房(fang)角發(fa)育異(yi)常(chang)，阻礙(ai)了房(fang)水(shui)排出所致(zhi)的疾病，表現為畏光(guang)、流淚(lei)及眼瞼痙攣、眼壓高，檢查有陽性(xing)發(fa)現。
(5)繼(ji)發(fa)(fa)性(xing)(xing)青光(guang)眼(yan)(yan)(yan)是一些(xie)眼(yan)(yan)(yan)部(bu)疾病和某(mou)些(xie)全身性(xing)(xing)疾病在眼(yan)(yan)(yan)部(bu)出(chu)現的合并癥(zheng)，它通過影響房水循環使眼(yan)(yan)(yan)壓升高。粘連性(xing)(xing)角膜白斑(ban)、虹(hong)膜睫狀體炎(yan)，外傷性(xing)(xing)眼(yan)(yan)(yan)內出(chu)血、房角挫傷、白內障膨(peng)脹期、虹(hong)膜新生血管等(deng)均可(ke)繼(ji)發(fa)(fa)青光(guang)眼(yan)(yan)(yan)。