白内障幻灯片

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,白内障幻灯片,cataract,成功医院,林雪媛,教学目的,理解白内障的发生原因及其分型。,掌握老年性白内障各型的特点。,掌握白内障的手术适应症及白内障术后矫正视力的方法。,理解先天性白内障和代谢性白内障的分型及特点。,理解晶状体脱位的分型及临床表现。,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状体,混浊使其透明性下降，称为白内障。,LENS,The lens is surrounded by a thick lens capsule which is the basement membran,ae,of the lens epithelial cells.,晶状体囊是一层包绕整个晶状体的透明囊状基底膜。,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 around the nucleus make up the cortex.,位于晶状体赤道部囊下的上皮细胞终生增殖，不断形成晶状体纤维，将旧的纤维挤向中心的核，核外较新较疏松的纤维构成皮质。,causes,Aging,most common,Long-term ultraviolet (UV) light, especially from sunlight,Diabetes or other systemic disease,Past eye infections, injuries or surgery,Smoking,Long-term use of certain medications (such as steroids),heredity,Pathogenesis,The 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 retina and interfering with vision.,晶状体主要由水和蛋白组成。,发生白内障的晶状体特征性改变是蛋白之间的交联形成聚合物，使光线散射增强，晶状体透明度下降。,自由基引起的氧化损伤,晶状体上皮细胞氧化损伤膜蛋白降解细胞膜通透性增加晶状体内浸透压增高、肿胀；晶体蛋白之间二硫键形成增多蛋白交联形成高分子量聚合物光散射增强，晶状体混浊。,细胞凋亡及其调控,normal Vs. cloudy lens,Clinical Findings,Symptoms,Blurring or dimness of vision 视力下降,colors appear faded 色觉改变,Sensitivity to light and glare 眩光,Double or multiple vision 复视或多视,Change in refraction 屈光改变,Eye Exam,Vision acuity test,Slit lamp,Ophthalmoscope,In most cases, eye drops are used to dilate (widen) pupils before the exam.,Tonometry,Slit lamp,classification,判断晶状体混浊范围和程度,将瞳孔充分散大，采用裂隙灯和后照法，区别晶状体混浊的类型,核性N、皮质性C、后囊下P、核的颜色NC,晶状体核硬度分级标准 据 NC,度：透明，无核，软性；,度：核呈黄白色或黄色，软核；,度：核呈深黄色，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，极硬核。,Age-related cataract,年龄相关性白内障是,最为常见的白内障类型，多见于50岁以上的中、老年人，随年龄增加其发病率升高。,There are three major types of cataract that are named depending on the location within the lens that is most affected. These are cortical, nuclear and posterior subcapsular. A given lens may have components of all three types of cataract.,根据晶状体开场出现混浊的部位，老年性白内障分为3种类型：皮质性、核性及后囊下白内障。一个晶状体可能同时发生这3型白内障。,Cortical cataract,the most common type of age-related cataract.,four stages as follows:,Incipient stage,初发期,Cortical changes may begin as small peripheral,water clefts.,皮质中空泡和水隙形成。,Radical pattern opacity.,放射状混浊。,检眼镜检查可见红光反射中放射状或片状阴影。,早期较周边的混浊并不影响视力，病程开展慢。,初发期,Intumescent stage,肿胀期,The lens takes up water, it becomes intumescent.,混浊加重，皮质吸水肿胀，晶状体体积增大。,Anterior chamber gets shallow.,前房变浅，有闭角型青光眼体质者可诱发青光眼急性发作。,斜照法检查,虹膜投影,现象。,视力明显下降，眼底难以窥清。,肿胀期,Mature stage,成熟期,Liquid escapes and the lens shrinks.,晶体内水分溢出，肿胀消退，体积变小。,The lens protein is totally opaque.,晶体完全混浊，呈乳白色。,视力降至手动或光感，眼底不能窥入。,成熟期,Hypermature Stage,过熟期,A long-standing or very mature cataract may undergo liquefaction of the lens cortex.,This liquid may escape through the intact capsule,leaving a shrunken lens with a wrinkled capsule.,在过度成熟的白内障，晶状体皮质液化。囊内水分可溢,出、肿胀消退，体积变小，囊膜发生皱缩。,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.,过熟期，棕黄色的晶状体核在囊内因重力而下沉，称,为Morgagnian白内障。,核下沉可使患者视力突然进步。,过熟期,hypermature,mature,Morganian,This slide shows a lens that has been removed at surgery.,Nuclear cataract,Early onset (after middle age).,起病早，一般中年后开场。,The earliest symptom may be improved near vision without glasses (“second sight).,早期病症可能是近视力改善称为“二次视力，这是由于白内障初期晶状体核屈光指数增加而产生近视所致。,Other symptoms may include poor hue discrimination or monocular diplopia.,其他病症可能包括颜色分辨力下降及单眼复视。,核性白内障,Posterior subcapsular cataract,Located in the cortex near the central posterior capsule.,位于后囊下浅皮质层。,It tends to cause visual symptoms earlier in their development owing to involvement of the visual axis.,混浊区位于视轴上，所以早期即可出现视力障碍。,Common symptoms include glare and reduced vision under bright lighting conditions.,一般病症包括眩光、强光下视力下降。,后囊下型白内障,Congenital Cataract,Present at birth or appear shortly thereafter.,于出生时或于生后短时间内即出现。,These cataracts may show many different patterns. The opacity may be confined to the area of the embryonic or fetal nucleus with clear cortex surrounding this.,形态学表现各异。混浊可能限于胎儿核周围。,Etiology,病因学,Intra-uterine,宫内因素,virus infection:,风疹病毒、巨细胞病毒等感染,Maternal ingestion of Thalidomide, steroids,孕期服用某些药物,.,Hereditary,遗传因素,autosomal dominant,常染色体显性遗传多见,recessive；X-linked 隐性和伴性遗传,Clinical findings临床表现,anterior polar cataract：,前极性白内障,posterior polar cataract:,后极性白内障,coronary cataract:,冠状白内障,punctate cataract:,点状白内障,perinuclear cataract:,绕核性白内障,nuclear cataract:,核性白内障,total cataract:,全白内障,membranous cataract:,膜性白内障,后极部白内障,冠状白内障,核性白内障,Treatment,Avoidance of amblyopia.,视觉正常发育受影响，易产生形觉剥夺性弱视。,Dense, central,larger than 2 mm in diameter congenital cataracts require surgery on an urgent basis.,位于中央且程度严重直径超过2mm 那么需尽早手术。,Traumatic cataract,外伤性白内障,Concussion,钝挫伤,Penetrating,穿通伤,Electric shock,电击伤,Radiation,辐射伤,眼球钝挫伤所致白内障,眼球穿通伤所致的白内障,电击所致的白内障,TREATMENT,影响视力不大的局限混浊，可随诊观察。,明显混浊影响视力的，应行手术治疗。,晶体破裂，皮质进入前房，可用糖皮质激素和降压药物，使病情控制后，手术摘出白内障，当皮质接触角膜内皮时，应考虑及早手术。,白内障摘出后应尽量植入,IOL,。,metabolic cataract,代谢性白内障,1. Diabetic cataract,-Senile cataract is accelerated,合并老年性白内障,-True diabetic cataract,真性糖尿病性白内障,2. Galactose cataract,半乳糖性白内障,3,.,tetany cataract,手足搐搦性白内障,糖尿病性白内障,Diabetic cataract,临床表现,糖尿病患者的年龄相关性白内障较多见，与无糖尿病的年龄相关性白内障相似，但发生较早，容易成熟。,真性糖尿病性白内障多发生于30岁以下，病情严重的幼年型糖尿病患者。常为双眼发病，进展迅速，晶体可能在数天、数周或数月内全混浊。,治 疗,应积极治疗糖尿病。在糖尿病白内障早期，严格控制血糖，晶体混浊可能会局部消退。当影响视力明显时，可在控制血糖下行白内障摘出术和IOL植入术，如有糖尿病性视网膜病变，宜在白内障手术前做视网膜光凝，手术后应继续治疗眼底病变。,半乳糖性白内障,Galactose cataract,为常染色体隐性遗传。患儿缺乏半乳糖-1-磷酸尿苷转移酶和半乳糖激酶，使半乳糖不能转化为葡萄糖而在体内积聚。组织内的半乳糖被醛糖复原酶复原为半乳糖醇。醇的浸透性极强，在晶体内的半乳糖醇吸水后，晶体囊膜破裂，引起晶体混浊。,诊断与,治疗,诊断：对先天性白内障患儿，应对尿中半乳糖进展挑选。如测定红细胞半乳糖-1-磷酸尿苷转移酶的活性，可明确诊断半乳糖-1-磷酸尿苷转移酶是否缺乏，应用放射化学法可测定半乳糖激酶的活性，有助于诊断。,治疗：给予无乳糖和半乳糖食品，可控制病情的开展或逆转白内障。,手足搐搦性白内障,tetany cataract,又称低钙性白内障，由血钙过低引起。低钙患者常有手足搐搦，因此又称手足搐搦性白内障。多由先天性甲状旁腺功能缺乏，或由于甲状腺手术损伤甲状旁腺以及营养不良所致。低钙增加了晶体囊膜的浸透性，影响了晶体的代谢。,临床表现：有,手足搐搦,、,骨质软化,和,白内障,三项典型改变。双眼晶体皮质前后皮质内有辐射状或条纹状混浊，与囊膜间有透明带隔开。囊膜下可见红、绿或蓝色结晶微粒。,诊断：有甲状腺手术史或营养障碍史，血钙过低，血磷升高。,治疗：给以足量的维生素,D,、钙剂，纠正低血钙，白内障明显时，可行手术治疗。,Complicated cataract,并发性白内障,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，眼部肿瘤,retinitis pigmentosa，视网膜色素变性,retinal detachment，视网膜脱离,常有眼部原发病的表现。,眼前段炎症疾病所致的由前皮质开场混浊。,临床表现,眼后段炎症所致,在晶体后极部囊膜下皮质、晶体核中心部和周边部呈放射状，玫瑰把戏混浊。,Drug-induced /toxic cataract,药物或中毒性白内障,Steroids： 糖皮质激素全身较局部使用发生率高,Chlorpromazine： 氯丙嗪,Metals： 金属铜、铁、汞等,Miotics： 缩瞳剂,Trinitrotoluene： 三硝基甲苯,After Cataract,后发性白内障,Opacifacation of the posterior capsule due to partially absorbed traumatic cataract or following extracapsular cataract extraction.,Persistent subcapsular lens epithelium may favor regeneration of lens fibers.,晶状体外伤后或白内障囊外摘出包括超声乳化手术,后，残留的皮质或晶状体上皮细胞增生，形成混浊。,After-cataract treatment,Unlike a cataract, an after-cataract is treated with a technique called laser capsulotomy.,后发性白内障的治疗不同于其他类型白内障，,激光囊膜切开是有效的方法。,The neodymium: YAG laser provides a noninvasive method for discission of the posterior capsule.,Nd : YAG激光囊膜切开术是一种后囊切开的非侵入性方法。,Pulses of laser energy creat a small hole in the posterior capsule in the pupillary axis.,激光能量瞬间传入靶组织引起小的“爆发，于瞳孔轴心的后囊内造成一个小洞。,Cataract Treatment,Surgery,is the only way,to,remove the cataract. 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.,手术适应症,视力的原因,医疗的原因,美容的原因,术前准备,What happens before surgery?,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,术前检查,全身检查,三大常规、心电图、胸透、血压、血糖、肝功能、肾功能。,局部检查,视功能、眼压、冲洗泪道、角膜曲率、A/B超,散瞳查晶体,结膜囊细菌培养,角膜内皮计数,眼电生理检查(EOG、ERG、VEP),白内障手术,手术方法,白内障囊内摘除术,(ICCE),白内障囊外摘除+人工晶体植入术,(ECCE),小切口白内障摘除+人工晶体植入术,超声乳化白内障摘除+人工晶体植入术,ECCE+IOL,Extracapsular cataract extraction is a preferred method of cataract surgery.,白内障囊外摘出术是目前主导的白内障手术。,It preserves the posterior portion of the lens capsule.,将混浊的晶状体核和皮质摘出而保存后囊膜。,Posterior chamber IOL can be implanted in the capsular sac.,后房型人工晶体得以植入晶状体囊内。,Phacoemulsification,Phacoemulsification 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 approximately 3mm.,超声乳化白内障吸除术是应用超声能量将混浊晶体核和皮质乳化后吸除，保存晶状体后囊。,it is the key to advanced , small-incision cataract surgery.,手术切口小，时间短。,Complications,手术并发症,posterior capsule opacification,后囊下混浊最常见,cystoid macular edema,黄斑囊样水肿,glaucoma,青光眼,hyphema,眼前房出血,ptosis,上睑下垂,infection,眼内炎 最严重,retinal detachment,视网膜脱离,lens dislocation,人工晶体位置异常,Cataract,Surgery,Inserting the new lens,白内障术后的视力矫正,白内障摘除后的无晶体眼呈高度远视状态一般达,+8D+10D,，矫正视力措施：,人工晶体植入,眼镜,角膜接触镜,Intraocular Lens,An IOL is a tiny, transparent, convex lens made of polymer which is inserted in the eye during surgery.,人工晶体是一种人工制造体积微小、透明的凸透镜，材料为高分子聚合物，具有良好的光学物理性能和组织相容性。,IOL,可折式,6mm,Foldable IOL,Anterior chamber,type,Posterior chamber,type,Advantages of IOL,Since the lens is placed inside the eye, the patient need not wear glasses for distant vision. 无需戴镜。,Images are clear and of the same dimension without distortion. 物像明晰，放大倍率小。,Full vision is obtained soon after surgery.,术后迅速恢复视力。,What happens after surgery?,If a small-incision technique is used, the postoperative recovery period is usually shortened.,采用小切口手术方式可以缩短术后恢复期。,The patient may be ambulatory on the day of surgery but is advised to move cautiously and avoid straining or heavy lifting for a month.,患者可能于手术当天即可自由行动，但是在一个月内应防止用力或抬举重物。,晶体异位和脱位,dislocation of lens,the lens is suspended on the ciliary body to maintain a definite situ by apparatus suspensorius lentis.,正常情况下晶状体由晶体悬韧带悬挂于睫状体上，其轴与视轴几乎一致。,Its positional abnormality has two causes: rupture of suspensory ligament induced by injury and congenital aplasia or weakness and laxation of the ligament, both can induce lens dislocation or subdislocation.,由于先天性、外伤或病变等原因使晶体悬韧带缺损或破裂，可引起悬挂力减弱，导致晶体异位或半脱位，假设悬韧带发生完全断裂，可产生晶体完全脱位。,晶体异位和脱位的分类,假设出生后晶体不在正常位置上，可称为晶体异位；,假设出生后因先天因素、外伤或病变使晶体位置改变，可统称为晶体脱位或半脱位。,但在先天性晶体位置异常的情况下，有时很难分清,何时发生晶体位置改变，因此，晶体脱位或异位并,无严格的分界，常常通用。,先天性晶体异位或脱位,外伤性晶体脱位,自发性晶体脱位,常染色体显性遗传病、表现双眼晶体脱位或半脱位、骨骼生长发育畸形、体格瘦长、肌肉软弱无力、肩胛下垂、合并心脏疾患。,Marfan,氏综合症,临床表现,单眼复视,检眼镜下见双重眼底形态,晶体脱入前房,裂隙灯下前房有油滴状透明体,晶体脱入玻璃体,前房变深，虹膜震颤，散瞳后见瞳孔内有透明球状物,晶体脱位的并发症,葡萄膜炎：,是晶体脱位常见的并发症。,继发性青光眼：,晶体脱入瞳孔区或玻璃体疝嵌顿在瞳孔，可产生瞳孔阻滞性青光眼。晶体溶解可产生溶解性青光眼。,视网膜脱离：,是严重的并发症，尤其在合并先天性异常的眼中，如Marfan症。,角膜混浊。,晶体脱位的治疗,根据晶体脱位的程度进展治疗：,晶体全脱位：脱入前房内或嵌于瞳孔区者应立即手术摘出。脱入玻璃体内，如无病症可观察，如发生炎症，需将晶体手术摘出。,晶体半脱位：如晶体透明，无病症和并发症时，可不必手术。可试用眼镜矫正视力，如有发生全脱位的可能，或眼镜不能矫正视力者，可考虑手术治疗。,谢谢大家！,