白內(nèi)障幻燈片課件

1、大家好打一疾病不紅不痛漸昏朦，薄霧輕煙漸漸濃。 初時(shí)一眼先昏暗，數(shù)日逐漸障雙瞳。千金難買藥見(jiàn)效，金針一撥當(dāng)日空。cataract勝利醫(yī)院林雪媛教學(xué)目的了解白內(nèi)障的發(fā)生原因及其分型。掌握老年性白內(nèi)障各型的特點(diǎn)。掌握白內(nèi)障的手術(shù)適應(yīng)癥及白內(nèi)障術(shù)后矯正視力的方法。了解先天性白內(nèi)障和代謝性白內(nèi)障的分型及特點(diǎn)。了解晶狀體脫位的分型及臨床表現(xiàn)。 What is cataract? A cataract is an opacity(or cloudy changes) of the lens that can cause vision problems. 任何先天性或后天性因素引起的晶狀體混濁使其透明性下降

2、，稱為白內(nèi)障。 LENSThe lens is surrounded by a thick lens capsule which is the basement membranae of the lens epithelial cells. 晶狀體囊是一層包繞整個(gè)晶狀體的透明囊狀基底膜。Epithelial cells at the lens equator continue to be produced throughout life,so that older lens fibers are compressed into a central nucleus; younger fibers

3、 around the nucleus make up the cortex.位于晶狀體赤道部囊下的上皮細(xì)胞終生增殖，不斷形成晶狀體纖維，將舊的纖維擠向中心的核，核外較新較疏松的纖維構(gòu)成皮質(zhì)。 causes Aging most commonLong-term ultraviolet (UV) light, especially from sunlight Diabetes or other systemic diseasePast eye infections, injuries or surgery Smoking Long-term use of certain medications

4、(such as steroids) heredity PathogenesisThe lens is made mostly of water and protein. The protein is arranged to let light pass through and focus on the retina. Sometimes some of the protein clumps together. This can start to cloud small areas of the lens, blocking some light from reaching the retin

5、a and interfering with vision. 晶狀體主要由水和蛋白組成。發(fā)生白內(nèi)障的晶狀體特征性改變是蛋白之間的交聯(lián)形成聚合物，使光線散射增強(qiáng)，晶狀體透明度下降。 自由基引起的氧化損傷 晶狀體上皮細(xì)胞氧化損傷膜蛋白降解細(xì)胞膜通透性增加晶狀體內(nèi)滲透壓增高、腫脹；晶體蛋白之間二硫鍵形成增多蛋白交聯(lián)形成高分子量聚合物光散射增強(qiáng)，晶狀體混濁。細(xì)胞凋亡及其調(diào)控 normal Vs. cloudy lensClinical FindingsSymptoms Blurring or dimness of vision 視力下降 colors appear faded 色覺(jué)改變 Sensiti

6、vity to light and glare 眩光 Double or multiple vision 復(fù)視或多視 Change in refraction 屈光改變 Eye ExamVision acuity test Slit lamp Ophthalmoscope In most cases, eye drops are used to dilate (widen) pupils before the exam.TonometrySlit lamp classification 判斷晶狀體混濁范圍和程度 將瞳孔充分散大，采用裂隙燈和后照法，區(qū)別晶狀體混濁的類型核性（N）、皮質(zhì)性（C）、

7、后囊下（P）、核的顏色（NC）晶狀體核硬度分級(jí)標(biāo)準(zhǔn) （據(jù) NC）度：透明，無(wú)核，軟性；度：核呈黃白色或黃色，軟核；度：核呈深黃色，中等硬度核；度：核呈棕色或琥珀色，硬核；度：核呈棕褐色或黑色，極硬核。Age-related cataract年齡相關(guān)性白內(nèi)障是最為常見(jiàn)的白內(nèi)障類型，多見(jiàn)于50歲以上的中、老年人，隨年齡增加其發(fā)病率升高。There are three major types of cataract that are named depending on the location within the lens that is most affected. These are cor

8、tical, nuclear and posterior subcapsular. A given lens may have components of all three types of cataract.根據(jù)晶狀體開(kāi)始出現(xiàn)混濁的部位，老年性白內(nèi)障分為3種類型：皮質(zhì)性、核性及后囊下白內(nèi)障。一個(gè)晶狀體可能同時(shí)發(fā)生這3型白內(nèi)障。Cortical cataract the most common type of age-related cataract. four stages as follows:Incipient stage 初發(fā)期Cortical changes may begin a

9、s small peripheral water clefts. 皮質(zhì)中空泡和水隙形成。Radical pattern opacity.放射狀混濁。檢眼鏡檢查可見(jiàn)紅光反射中放射狀或片狀陰影。早期較周邊的混濁并不影響視力，病程發(fā)展慢。初發(fā)期Intumescent stage 腫脹期The lens takes up water, it becomes intumescent.混濁加重，皮質(zhì)吸水腫脹，晶狀體體積增大。Anterior chamber gets shallow.前房變淺，有閉角型青光眼體質(zhì)者可誘發(fā)青光眼急性發(fā)作。斜照法檢查虹膜投影現(xiàn)象。視力明顯下降，眼底難以窺清。腫脹期Mature

10、stage 成熟期Liquid escapes and the lens shrinks.晶體內(nèi)水分溢出，腫脹消退，體積變小。The lens protein is totally opaque.晶體完全混濁，呈乳白色。視力降至手動(dòng)或光感，眼底不能窺入。成熟期Hypermature Stage 過(guò)熟期A long-standing or very mature cataract may undergo liquefaction of the lens cortex. This liquid may escape through the intact capsule,leaving a shru

11、nken lens with a wrinkled capsule.在過(guò)度成熟的白內(nèi)障，晶狀體皮質(zhì)液化。囊內(nèi)水分可溢出、腫脹消退，體積變小，囊膜發(fā)生皺縮。 The dark brown, mature nucleus which sinks inferiorly in the fluid filled capsular sac due to the forces of gravity. is called a Morgagnian cataract.過(guò)熟期，棕黃色的晶狀體核在囊內(nèi)因重力而下沉，稱為Morgagnian白內(nèi)障。核下沉可使患者視力突然提高。過(guò)熟期hypermature mature

12、Morganian This slide shows a lens that has been removed at surgery.Nuclear cataractEarly onset (after middle age).起病早，一般中年后開(kāi)始。 The earliest symptom may be improved near vision without glasses (“second sight”). 早期癥狀可能是近視力改善（稱為“二次視力”），這是由于白內(nèi)障初期晶狀體核屈光指數(shù)增加而產(chǎn)生近視所致。Other symptoms may include poor hue disc

13、rimination or monocular diplopia.其他癥狀可能包括顏色分辨力下降及單眼復(fù)視。 核性白內(nèi)障Posterior subcapsular cataractLocated in the cortex near the central posterior capsule.位于后囊下淺皮質(zhì)層。It tends to cause visual symptoms earlier in their development owing to involvement of the visual axis.混濁區(qū)位于視軸上，所以早期即可出現(xiàn)視力障礙。Common symptoms in

14、clude glare and reduced vision under bright lighting conditions.一般癥狀包括眩光、強(qiáng)光下視力下降。 后囊下型白內(nèi)障Congenital CataractPresent at birth or appear shortly thereafter.于出生時(shí)或于生后短時(shí)間內(nèi)即出現(xiàn)。These cataracts may show many different patterns. The opacity may be confined to the area of the embryonic or fetal nucleus with c

15、lear cortex surrounding this. 形態(tài)學(xué)表現(xiàn)各異?；鞚峥赡芟抻谔汉酥車tiology 病因?qū)W Intra-uterine 宮內(nèi)因素virus infection: 風(fēng)疹病毒、巨細(xì)胞病毒等感染Maternal ingestion of Thalidomide, steroids, 孕期服用某些藥物. Hereditary 遺傳因素 autosomal dominant 常染色體顯性遺傳多見(jiàn) recessive；X-linked 隱性和伴性遺傳Clinical findings臨床表現(xiàn) anterior polar cataract：前極性白內(nèi)障posterior

16、polar cataract:后極性白內(nèi)障coronary cataract:冠狀白內(nèi)障punctate cataract:點(diǎn)狀白內(nèi)障perinuclear cataract: 繞核性白內(nèi)障nuclear cataract: 核性白內(nèi)障total cataract: 全白內(nèi)障membranous cataract: 膜性白內(nèi)障后極部白內(nèi)障冠狀白內(nèi)障核性白內(nèi)障TreatmentAvoidance of amblyopia.視覺(jué)正常發(fā)育受影響，易產(chǎn)生形覺(jué)剝奪性弱視。Dense, central,larger than 2 mm in diameter congenital cataracts re

17、quire surgery on an urgent basis.位于中央且程度嚴(yán)重直徑超過(guò)2mm 則需盡早手術(shù)。Traumatic cataract外傷性白內(nèi)障Concussion 鈍挫傷Penetrating 穿通傷Electric shock 電擊傷Radiation 輻射傷眼球鈍挫傷所致白內(nèi)障眼球穿通傷所致的白內(nèi)障電擊所致的白內(nèi)障TREATMENT影響視力不大的局限混濁，可隨診觀察。明顯混濁影響視力的，應(yīng)行手術(shù)治療。晶體破裂，皮質(zhì)進(jìn)入前房，可用糖皮質(zhì)激素和降壓藥物，使病情控制后，手術(shù)摘出白內(nèi)障，當(dāng)皮質(zhì)接觸角膜內(nèi)皮時(shí)，應(yīng)考慮及早手術(shù)。白內(nèi)障摘出后應(yīng)盡量植入IOL。metabolic ca

18、taract代謝性白內(nèi)障 1. Diabetic cataract -Senile cataract is accelerated 合并老年性白內(nèi)障 -True diabetic cataract 真性糖尿病性白內(nèi)障 2. Galactose cataract 半乳糖性白內(nèi)障 3. tetany cataract 手足搐搦性白內(nèi)障 糖尿病性白內(nèi)障Diabetic cataract 臨床表現(xiàn)糖尿病患者的年齡相關(guān)性白內(nèi)障較多見(jiàn)，與無(wú)糖尿病的年齡相關(guān)性白內(nèi)障相似，但發(fā)生較早，容易成熟。真性糖尿病性白內(nèi)障多發(fā)生于30歲以下，病情嚴(yán)重的幼年型糖尿病患者。常為雙眼發(fā)病，進(jìn)展迅速，晶體可能在數(shù)天、數(shù)周或數(shù)月

19、內(nèi)全混濁。治 療應(yīng)積極治療糖尿病。在糖尿病白內(nèi)障早期，嚴(yán)格控制血糖，晶體混濁可能會(huì)部分消退。當(dāng)影響視力明顯時(shí)，可在控制血糖下行白內(nèi)障摘出術(shù)和IOL植入術(shù)，如有糖尿病性視網(wǎng)膜病變，宜在白內(nèi)障手術(shù)前做視網(wǎng)膜光凝，手術(shù)后應(yīng)繼續(xù)治療眼底病變。半乳糖性白內(nèi)障Galactose cataract 為常染色體隱性遺傳?；純喝狈Π肴樘?1-磷酸尿苷轉(zhuǎn)移酶和半乳糖激酶，使半乳糖不能轉(zhuǎn)化為葡萄糖而在體內(nèi)積聚。組織內(nèi)的半乳糖被醛糖還原酶還原為半乳糖醇。醇的滲透性極強(qiáng)，在晶體內(nèi)的半乳糖醇吸水后，晶體囊膜破裂，引起晶體混濁。診斷與治療診斷：對(duì)先天性白內(nèi)障患兒，應(yīng)對(duì)尿中半乳糖進(jìn)行篩選。如測(cè)定紅細(xì)胞半乳糖-1-磷酸尿苷轉(zhuǎn)移

20、酶的活性，可明確診斷半乳糖-1-磷酸尿苷轉(zhuǎn)移酶是否缺乏，應(yīng)用放射化學(xué)法可測(cè)定半乳糖激酶的活性，有助于診斷。治療：給予無(wú)乳糖和半乳糖食品，可控制病情的發(fā)展或逆轉(zhuǎn)白內(nèi)障。手足搐搦性白內(nèi)障tetany cataract 又稱低鈣性白內(nèi)障，由血鈣過(guò)低引起。低鈣患者常有手足搐搦，因此又稱手足搐搦性白內(nèi)障。多由先天性甲狀旁腺功能不足，或由于甲狀腺手術(shù)損傷甲狀旁腺以及營(yíng)養(yǎng)不良所致。低鈣增加了晶體囊膜的滲透性，影響了晶體的代謝。臨床表現(xiàn)：有手足搐搦、骨質(zhì)軟化和白內(nèi)障三項(xiàng)典型改變。雙眼晶體皮質(zhì)前后皮質(zhì)內(nèi)有輻射狀或條紋狀混濁，與囊膜間有透明帶隔開(kāi)。囊膜下可見(jiàn)紅、綠或藍(lán)色結(jié)晶微粒。診斷：有甲狀腺手術(shù)史或營(yíng)養(yǎng)障礙史，

21、血鈣過(guò)低，血磷升高。治療：給以足量的維生素D、鈣劑，糾正低血鈣，白內(nèi)障明顯時(shí)，可行手術(shù)治療。Complicated cataract并發(fā)性白內(nèi)障Develop as a direct effect of eye diseases upon the physiology of the lens,such as ：glaucoma，青光眼 iritis，虹膜炎eye tumors，眼部腫瘤retinitis pigmentosa，視網(wǎng)膜色素變性 retinal detachment，視網(wǎng)膜脫離常有眼部原發(fā)病的表現(xiàn)。眼前段炎癥疾病所致的由前皮質(zhì)開(kāi)始混濁。臨床表現(xiàn)眼后段炎癥所致 在晶體后極部囊膜下皮質(zhì)

22、、晶體核中心部和周邊部呈放射狀，玫瑰花樣混濁。 Drug-induced /toxic cataract藥物或中毒性白內(nèi)障Steroids： 糖皮質(zhì)激素全身較局部使用發(fā)生率高Chlorpromazine： 氯丙嗪Metals： 金屬（銅、鐵、汞等） Miotics： 縮瞳劑 Trinitrotoluene： 三硝基甲苯After Cataract 后發(fā)性白內(nèi)障Opacifacation of the posterior capsule due to partially absorbed traumatic cataract or following extracapsular cataract

23、 extraction.Persistent subcapsular lens epithelium may favor regeneration of lens fibers.晶狀體外傷后或白內(nèi)障囊外摘出（包括超聲乳化）手術(shù)后，殘留的皮質(zhì)或晶狀體上皮細(xì)胞增生，形成混濁。 After-cataract treatmentUnlike a cataract, an after-cataract is treated with a technique called laser capsulotomy.后發(fā)性白內(nèi)障的治療不同于其他類型白內(nèi)障， 激光囊膜切開(kāi)是有效的方法。The neodymium:

24、YAG laser provides a noninvasive method for discission of the posterior capsule.Nd : YAG激光囊膜切開(kāi)術(shù)是一種后囊切開(kāi)的非侵入性方法。Pulses of laser energy creat a small hole in the posterior capsule in the pupillary axis.激光能量瞬間傳入靶組織引起小的“爆發(fā)”，于瞳孔軸心的后囊內(nèi)造成一個(gè)小洞。 Cataract TreatmentSurgery is the only way to remove the cataract

25、. However, if symptoms from a cataract are mild, a change of glasses may be all that is needed for you to function more comfortably. Cataract surgery should be considered when cataracts cause enough loss of vision to interfere with daily activities. 手術(shù)適應(yīng)癥 視力的原因 醫(yī)療的原因 美容的原因 術(shù)前準(zhǔn)備What happens before su

26、rgery?A week or two before surgery, some tests should be done, including:Visual acuity,intraocular pressure, slit lamp, ophthalmoscope To measure the curve of the cornea and the size and shape of the eye. systemic exam: hypertension, diabetes and other disorders術(shù)前檢查全身檢查 三大常規(guī)、心電圖、胸透、血壓、血糖、肝功能、腎功能。局部檢

27、查 視功能、眼壓、沖洗淚道、角膜曲率、A/B超 散瞳查晶體 結(jié)膜囊細(xì)菌培養(yǎng) 角膜內(nèi)皮計(jì)數(shù) 眼電生理檢查(EOG、ERG、VEP)白內(nèi)障手術(shù) 手術(shù)方法 白內(nèi)障囊內(nèi)摘除術(shù)(ICCE) 白內(nèi)障囊外摘除+人工晶體植入術(shù)(ECCE) 小切口白內(nèi)障摘除+人工晶體植入術(shù) 超聲乳化白內(nèi)障摘除+人工晶體植入術(shù)ECCE+IOLExtracapsular cataract extraction is a preferred method of cataract surgery. 白內(nèi)障囊外摘出術(shù)是目前主導(dǎo)的白內(nèi)障手術(shù)。It preserves the posterior portion of the lens ca

28、psule.將混濁的晶狀體核和皮質(zhì)摘出而保留后囊膜。Posterior chamber IOL can be implanted in the capsular sac.后房型人工晶體得以植入晶狀體囊內(nèi)。PhacoemulsificationPhacoemulsification or phaco refers to ultra-sonic vibration which dissolves the hard nucleus such that the nuclear material and cortex can be aspired through an incision of appro

29、ximately 3mm. 超聲乳化白內(nèi)障吸除術(shù)是應(yīng)用超聲能量將混濁晶體核和皮質(zhì)乳化后吸除，保留晶狀體后囊。it is the key to advanced , small-incision cataract surgery.手術(shù)切口小，時(shí)間短。Complications 手術(shù)并發(fā)癥posterior capsule opacification 后囊下混濁最常見(jiàn)cystoid macular edema 黃斑囊樣水腫glaucoma 青光眼hyphema 眼前房出血ptosis 上瞼下垂infection 眼內(nèi)炎 最嚴(yán)重retinal detachment 視網(wǎng)膜脫離 lens disloc

30、ation 人工晶體位置異常CataractSurgeryInserting the new lens白內(nèi)障術(shù)后的視力矯正 白內(nèi)障摘除后的無(wú)晶體眼呈高度遠(yuǎn)視狀態(tài)一般達(dá)+8D+10D，矯正視力措施： 人工晶體植入 眼鏡 角膜接觸鏡Intraocular LensAn IOL is a tiny, transparent, convex lens made of polymer which is inserted in the eye during surgery. 人工晶體是一種人工制造體積微小、透明的凸透鏡，材料為高分子聚合物，具有良好的光學(xué)物理性能和組織相容性。IOL可折式 6mmFolda

31、ble IOLAnterior chamber typePosterior chambertypeAdvantages of IOLSince the lens is placed inside the eye, the patient need not wear glasses for distant vision. 無(wú)需戴鏡。Images are clear and of the same dimension without distortion. 物像清晰，放大倍率小。Full vision is obtained soon after surgery. 術(shù)后迅速恢復(fù)視力。What happens after surgery?If a small-incision technique is used, the postoperative recovery period is usually shortened. 采用小切口手術(shù)方式可以縮短術(shù)后恢復(fù)期。The patient may be ambulatory on the day of surgery but is advised to move cautiously and avoid straining or heav