老年人的视力问题 Mr Thomas Fenech FRCS, FRCOphth Consultant Ophthalmic Surgeon St Luke’s Hospital Malta 翻译:陈建华

引起视力下降的主要原因 白内障 黄斑病变 晚期青光眼 糖尿病视网膜病变 视网膜血管性疾病 脑血管病

白 内 障 晶状体混浊 据估计约有2千万人因白内障而失明 在美国每年约有1，500，000白内障需要手术治疗 白 内 障 晶状体混浊 据估计约有2千万人因白内障而失明 在美国每年约有1，500，000白内障需要手术治疗 >70岁年龄组中约95％的年龄相关性白内障患者引 起视力损害的原因是多因素年致

白内障的症状 近视度数的增加 视力逐渐减退 阅读困难 在亮处视物不清 眩光 重影

引起白内障的危险因素 吸烟 长时间脱水 长时间的紫外线照射 激素、缩瞳剂等药物的治疗 外伤史 糖尿病

白内障的分级 未成熟期白内障 稳定期白内障 进展期白内障 成熟期白内障 膨胀期白内障 过熟期白内障

黄斑病变 黄斑病变在西方引起盲的主要原因（在英国和美国 约30％的盲是由黄斑病变引起） 不可逆性视力损害 无有效的治疗方法 双眼发病的不对称性

黄斑病变 >60岁的超过95％的视力损害是由黄斑病变所致， 还有一部分是由中高度近视所致 多见白种人 黄斑病变有干、湿性两种类型 湿性黄斑病变严重影响中心视力

AMD中新生血管是导致视力下降的最主要因素 由于RPE的萎缩导致的黄斑病变<5% 80-90%的黄斑病变由于新生血管形成 约5-10%由于RPE浆液性脱离导致的黄斑病变 Neovascular AMD is characterized by choroidal neovascularization (CNV), in which new blood vessels proliferate and grow through breaks in Bruch’s membrane. CNV is responsible for approximately 80–90% of cases of severe, irreversible central vision loss associated with AMD. Other causes of vision loss, including serous detachment and geographic atrophy, account for a much smaller proportion of vision loss. References: Hyman 1992 Ferris III et al. 1984 Figure taken from Monograph Figure 2.3

黄斑区新生血管的形成 其中8％的患者有新生血管 CNV可以引起85%的AMD患者严重的视力损失 While laser photocoagulation is beneficial in some patients, it has several limitations. It has been estimated that only 13 to 26% of patients with neovascular AMD are eligible for treatment. Patients may be considered ineligible if they have lesions that: do not contain some classic CNV, lack a well-defined boundary, or that exceed 3.5 MPS disc areas. Although laser photocoagulation may reduce the risk of vision loss in selected patients in the long term, the thermal laser often causes irreversible retinal damage and an absolute scotoma, which can lead to an immediate loss of visual acuity. Furthermore, a 3-year follow-up of eyes with subfoveal CNV that were treated with laser photocoagulation showed that leakage from CNV persisted or recurred in approximately 50% of eyes. References: Ciulla 1998 MPS Study Group 1994 Text derived from Key Message Data Support Compendium: fact sheet B4

什么是年龄相关性黄斑病变 AMD is a degenerative retinal disease that can cause distortion of vision accompanied by a rapid loss of central vision. In the western world, AMD is becoming more prevalent as the population ages and is now the leading cause of severe vision loss in people over 50 years of age. References: O’Shea, J.G. 1998

AMD的流行病学调查 四个大规模AMD流行病学研究结果如下 Beaver Dam Eye Study (8.4–37%) Framingham Eye Study (1.6– 28%) Blue Mountains Eye Study (0– 19%) Rotterdam Eye Study (0.2– 11%) Several epidemiologic studies have estimated the prevalence of all forms of AMD. The four largest studies, one conducted in the mid-1970s and the others in the 1990s, examined populations over the age of 40 to 50 years in: - Beaver Dam, Wisconsin - Framingham, Massachusetts - Rotterdam in the Netherlands - the Blue Mountains in Australia In these studies, the estimates of the population-based prevalence of AMD ranged from 0% to 8.4% in the youngest age groups (43 to 64 years) and from 11% to 37% in the oldest age groups (older than 75 or 85 years). The variation between the studies depended on the definition of AMD, the grading system used, the age categories into which the populations were divided, and the environment of the study population. While the precise figures vary, studies agree that the risk of developing AMD increases with age. References: Rotterdam Eye Study: Vingerling 1995 Blue Mountains Eye Study: Mitchell 1995 Beaver Dam Eye Study: Klein 1992 Framingham Eye Study: Kahn 1977

年龄和AMD The Rotterdam Eye Study（鹿 特丹眼病研究） 随年龄增长AMD患病率增高 患病率 (%) For example, in the Rotterdam Eye Study the prevalence of AMD was more than 50 times greater in people over 85 years of age than in those between 55 and 64 years of age. References: Vingerling 1995 Age group (years)

>65岁人群AMD患病率呈上升趋势 年龄的增长是AMD患病率上升 的最危险的因素 People aged 60 years (%) 年龄的增长是AMD患病率上升 的最危险的因素 到2020年>65岁约7，500， 000人会因AMD而丧失视力 Since AMD affects older people, its prevalence will increase significantly as the average age of the world population increases. In 1990, approximately 18% of the population of the western world was over 60 years of age. By 2020 this is expected to have increased to over 23%. It has been estimated that by 2020 the prevalence of AMD will be three times greater than it was in 1995, with up to 7.5 million people over 65 years of age suffering from AMD-related vision loss. References: Thylefors 1995 Figure taken from Monograph figure 2.1

AMD的新生血管的发展 正常视网膜 Photoreceptors RPE Choroid In a normal retina, the RPE separates the choroidal layer from the retinal neurons or photoreceptors. The choroidal layer provides the blood supply to the retina. When the RPE is intact, it blocks the inward migration of small molecules from the choriocapillaris into the subretinal space. Reference: Kincaid 1992 Choroid 正常视网膜

AMD的新生血管的发展: 玻璃膜疣的发展 玻璃氏膜变厚和玻璃膜疣的进一步发展 Drusen (arrowed) are the first clinically detectable signs of AMD. There is accumulation of debris, with thickening of the basement membrane of the RPE (Bruch’s membrane). Reference: Kincaid 1992 玻璃氏膜变厚和玻璃膜疣的进一步发展

AMD的新生血管的发展 新血管的形成 新生血管的增殖、穿透玻璃氐膜 In neovascular AMD, the development of soft, diffuse drusen is associated with breaks in Bruch’s membrane. These breaks may provide sites through which new abnormal blood vessels, or CNV (arrowed), grow and proliferate from the underlying choriocapillaris. References: Kincaid 1992 Alexander 1993 新生血管的增殖、穿透玻璃氐膜

AMD的新生血管的发展 液体和血液从新生血管中渗漏 从新血管中渗漏血液和液体 These new abnormal blood vessels are fragile and leak blood (arrows) and fluid, which can lead to detachment of the RPE or neurosensory retina, formation of a fibrovascular scar, and a loss of outer retinal tissue. These changes lead to distorted vision and may result in profound, irreversible vision loss. 从新血管中渗漏血液和液体

AMD的危险因素 除了年龄外患AMD的 危险因素还有： 性别 种族 遗传因素 家族史 高血压和心血管性疾病 吸烟 兰光的照射 营养 The greatest risk factor for AMD is increasing age, although a number of other risk factors have been suggested. At present, it is thought that AMD is caused by a combination of genetic and environmental factors. Some studies have implicated gender as a risk factor. The Beaver Dam Eye Study, for instance, found that women were twice as likely to develop neovascular AMD as men. References: Klein 1997 Klein 1992 Zhang 1995

双眼AMD的危险因素 一只眼是湿性AMD，另一眼也易患湿性AMD。 42%的单眼湿性AMD患者5年以上，常会累及另一眼。 Once one eye is affected, there is a greatly increased risk that neovascular AMD will develop in the fellow eye within 3–5 years. The risk of developing CNV is higher in fellow eyes that have numerous, large or confluent drusen and focal hyperpigmentation. The annual reported rate of second eye involvement ranges from 4% to 12%. Within 5 years, an average of 42% of patients with neovascular AMD in one eye will develop it in the other. The development of neovascular AMD in the first eye is often masked by the fellow eye compensating for lost vision, which emphasizes the importance of regular eye examinations to detect early symptoms. References: Pieramici and Bressler 1998 Macular Photocoagulation Study Group 1997

AMD的症状 中心视力的丧失 中心盲点 对比敏感度下降 色常减退 Patients who develop neovascular AMD are likely to experience a number of symptoms, including reduced central visual acuity and central scotoma (blind spots) in the visual field. Metamorphopsia (distorted vision), decreased contrast sensitivity (the ability to distinguish between visual targets), and decreased color vision are also reported by many of these patients. Reference: Dolan 1996

AMD对患者视功能的影响 湿性AMD患者阅读可能困难 阅读困难 看不清时间 识别困难 驾驶困难 Loss of central vision can have a severe effect on the quality of life of patients with neovascular AMD. Patients may have increasing difficulty with normal daily tasks and activities, such as reading, telling the time, recognizing faces, or driving. The consequences are particularly severe if both eyes are affected. Reference: Owsley and Sloane 1987

AMD对患者生活质量的影响 由于视力的损失导致患者生活质量的降低 与患有关节炎、慢性阻塞性肺病、或者是AID患者 一样 日常生活都需要别人的帮助 更易出现焦虑和压抑 Vision impairment due to neovascular AMD can significantly reduce a patient’s ability to cope with basic aspects of everyday life. The loss of independence, productivity and self-esteem can, in some cases, lead to psychological problems such as anxiety, depression, anger, reduced drive, tiredness, and confusion. Studies of quality of life in patients with neovascular AMD have shown that the mean scores are comparable with those of patients with arthritis, chronic obstructive pulmonary disease, or AIDS. Compared with healthy people of a similar age, AMD patients are more likely to need help with daily activities and to suffer from anxiety or depression. References: Williams et al. 1998

AMD的治疗 AMD应早期发现和早期治疗 视力损害的患者可以用助视镜和盲文教育 激光治疗 Early recognition of neovascular AMD is important if patients are to be referred quickly to ophthalmologists and be given treatment that may reduce the risk of vision loss, if appropriate. Until recently, the only available treatment was laser photocoagulation, which is helpful only to a minority of patients, but can cause acute retinal damage with vision loss. Visudyne therapy is a new treatment option that has recently been shown to be safe and effective in reducing the risk of vision loss in selected cases, with less damage than might occur with laser photocoagulation. Patients who are not eligible for either laser photocoagulation or Visudyne therapy may benefit from the use of low vision aids and education.

激光光凝的局限性 只有13-26%湿性AMD的患者符合激光的条件 激光治疗可以导致不可逆性损害和视野的绝对 暗点 激光后视力下降 激光后渗漏仍有，还可能约50%的患者激光后 复发 While laser photocoagulation is beneficial in some patients, it has several limitations. It has been estimated that only 13 to 26% of patients with neovascular AMD are eligible for treatment. Patients may be considered ineligible if they have lesions that: do not contain some classic CNV, lack a well-defined boundary, or that exceed 3.5 MPS disc areas. Although laser photocoagulation may reduce the risk of vision loss in selected patients in the long term, the thermal laser often causes irreversible retinal damage and an absolute scotoma, which can lead to an immediate loss of visual acuity. Furthermore, a 3-year follow-up of eyes with subfoveal CNV that were treated with laser photocoagulation showed that leakage from CNV persisted or recurred in approximately 50% of eyes. References: Ciulla 1998 MPS Study Group 1994 Text derived from Key Message Data Support Compendium: fact sheet B4

AMD治疗的新进展 光动力治疗 手术 放疗 抗新生血管性药物的应用 经瞳孔温热疗法 Although Visudyne therapy and laser photocoagulation are the only treatments that have been proven to be effective in randomized clinical trials, several other treatments are being investigated. These include a number of new photosensitizers, a variety of surgical techniques, radiation therapy, several antiangiogenic drugs, and transpupillary thermotherapy. It will take several more years before any of these will have sufficient data to support their use. The would also need to satisfactorily prove that they are at least as effective as Visudyne therapy.

慢性开角型青光眼 70岁以上的患病率在5% 10%的盲人中是由开青所致 好发于黑人 视杯盘的变化 眼压升高 视野的丢失

青光眼的患病率 占总人口的1-2％。 40岁以上者为2.5%。 70岁以上者为5.0%。 与年龄相关性强。 5％患者可导致盲。

青光眼的危险因素 黑人。 家族史。 40岁以上人群。 近视。 糖尿病。 高血压。

青光眼 青光眼患者早期视野的丢失从周边开始，晚期管视 。 晚期青光眼患者尽管还残存一些阅读视力，可主要 问题是远视力的丢失 对比敏感度和明暗视的降低

0.02或更好的视力患者半数都可以独立生活。

一个视力在短期内下降的老人不可能像年轻人容易 适应视力下降

康复训练 放大，提高高度对比度 很好的利用残存视力 训练适应日常的生活活动 咨询服务

助视器 放大镜 手持放大镜 台式放大镜 望远镜 视频放大器

助视器

大的阅读字体 大的电话按钮 会说话的闹钟 烤箱的显示面板上突出标记