低眼壓時，如何確診急性青光眼？這確實是個讓人頭疼的問題。

這是一本經(jīng)典的青光眼專著，在青光眼界的熱鬧程度不及其他。

今天分享3個病例，前兩個是從理論角度“編寫”的，最后一個是實例。

1.   A patient presents a day or 2 after the onset of symptoms in one eye. The history reveals having experienced an acute onset of pain and blurred vision. Within an hour after the onset of symptoms, the patient developed severe pain and blurring of vision. He took some aspirin and went to bed. Overnight, the symptoms became less severe. The vision was much improved though still a little blurred, and there was no longer any discomfort.

病人主訴單眼受累1～2天，疼痛急性發(fā)作，伴視物模糊。嚴(yán)重疼痛和視物模糊1小時后，口服阿斯匹林，然后睡覺。一夜過后，癥狀減輕，視物仍有模糊，但明顯改善，其他癥狀消退。

Examination reveals a slightly congested eye, or an eye that may be white and quiet. The pupil is somewhat dilated and reacts sluggishly. There are folds in the posterior surface of the cornea and cells in the aqueous. There may be one or more posterior synechiae. Glaukomflecken may or may not be present. IOP is lower than in the fellow eye. If the cornea is clear enough, on gonioscopy, the angle can be seen to be extremely narrow or closed. The angle in the fellow eye is also found to be extremely narrow.

檢查見眼部輕度充血，甚至無充血，瞳孔略有擴(kuò)大，反應(yīng)遲鈍。角膜后表面有皺褶，房水見細(xì)胞。瞳孔有一點(diǎn)或多點(diǎn)后粘連。青光眼斑有或無。眼壓較對側(cè)眼低。如果角膜透明程度允許房角鏡檢查，可以看到房角很窄，接近關(guān)閉，對側(cè)眼房角同樣很窄。

The finding of folds in the cornea and of cells in the aqueous along with posterior synechiae in conjunction with a normal or subnormal IOP may point the clinician toward a diagnosis of iritis. However, the history of a typically monocular disorder with acute onset, the dilation of the pupil, and the gonioscopic examination of the angle of the affected eye and of the fellow eye should lead to the correct diagnosis of spontaneous recovery from an attack of acute angle-closure glaucoma.

角膜皺褶和房水細(xì)胞，加上后粘連和眼壓正?；蚵缘停R床診斷可能會偏向虹膜炎。實際上，這是典型的單眼青光眼急性發(fā)作，受累眼的瞳孔散大和房角鏡檢查結(jié)果，以及對側(cè)眼的房角檢查所見，這些都指向：閉青急性發(fā)作，然后自行緩解。

It is not at all uncommon in this type of case for a misdiagnosis of iritis to be made and for topical steroids and cycloplegics to be prescribed. In response, the IOP may remain normal, and the eye may promptly resolve its inflammatory appearance. Anterior chamber cells may disappear. Nevertheless, the patient may show up the next week or sometime thereafter with recurrence of an attack of typical acute angle-closure glaucoma.

這類誤診為虹膜炎的情況并非少見，然后就是誤治：局部激素，加上睫狀肌麻痹劑。治療后，眼壓可能就恢復(fù)正常，眼睛的炎癥也得到相應(yīng)緩解，前房細(xì)胞消失。盡管如此，下周或者此后某個時間，病人的典型急性閉青將再次發(fā)作。

2.   A patient presents with a history of acute onset of pain and blurred vision 1 or more days previously, with partial recovery of vision and disappearance of pain. Examination reveals little or no congestion of the eye. There may be cells in the aqueous or folds in the cornea. IOP is normal or subnormal. Examination of the fundus reveals disc swelling and many retinal hemorrhages throughout the posterior pole. Vision is fairly good.

病人有1天或幾天的疼痛和視物模糊急性發(fā)作，視物模糊部分緩解，疼痛消退，檢查見輕度或沒有充血，房水有細(xì)胞，角膜可能也有皺褶，眼壓正常或略低，眼底可見視盤腫脹，視網(wǎng)膜后極部有不少出血，視力還好。

At first glance, one might consider a diagnosis of optic neuritis or venous occlusion, but the history of a very acute onset of symptoms, with pain and blurred vision, would be inconsistent with such a diagnosis. Also, the subsequent rapid visual recovery to near normal would not be consistent with occlusion of the central retinal vein or with optic neuritis. Gonioscopic examina tion reveals the most important cluean extremely narrow angle that may or may not show areas of closure. The angle in the fellow eye is also found to be extremely narrow.

乍看起來，要考慮視神經(jīng)炎或者靜脈阻塞，但是急性疼痛和視物模糊的病史不支持這些診斷，隨后的視力較快恢復(fù)也與網(wǎng)膜靜脈阻塞或者視神經(jīng)炎并不相符。房角鏡檢查能夠發(fā)現(xiàn)特別重要的線索房角很窄，近乎關(guān)閉，對側(cè)眼房角也很窄。

Now the correct diagnosis is made. The patient has had spontaneous recovery from an attack of acute angle closure, resulting in temporary hypotony, swelling of the disc, and hemorrhages in the fundus. If the diagnosis was missed, one could expect a recurrence of acute angle closure a few weeks later with a very high IOP and all the characteristic findings.

由此不難做出正確診斷，病人是閉青急性發(fā)作后的自行緩解，導(dǎo)致一過性低眼壓、視盤腫脹和眼底出血。如果誤診，伴眼壓顯著升高和其他特征性體征的急閉發(fā)作，為期不遠(yuǎn)。

3.   A 46-year-old woman, seen 40 years previously, gave a history of having developed iritis in the right eye while on a cruise and having been given atropine ointment. When she returned home, her local ophthalmologist continued this treatment. Finally, the eye became completely quiet and she was referred for consultation. Corrected vision was 6/5 in each eye. The media were clear. Discs were normal. Visual fields were full. The anterior chambers were shallow.

The right pupil was 4 by 5 mm and displaced slightly temporally, and the left pupil was 3 mm, round, and central. Atrophy of the iris was noted temporally in the right eye. On slit-lamp examination, there were some whitish flecks that seemed to be just beneath the anterior lens capsule. IOP was not measured. Gonioscopy was not done in those days.

40年前的一個病例。46歲女性，右眼虹膜炎史，旅游時發(fā)作，曾被給予阿托品眼膏治療。旅游回家后，當(dāng)?shù)匮劭漆t(yī)生繼續(xù)同樣治療。眼睛完全康復(fù)后，轉(zhuǎn)診來尋求?？埔庖姟ｋp眼矯正視力都是1.2，屈光介質(zhì)清晰，視盤正常，視野未見缺損，前房淺，右眼瞳孔4～5mm，輕度偏向顳側(cè)，左眼瞳孔3mm，圓，居中。右眼顳側(cè)虹膜有萎縮。晶狀體囊膜下有些白色斑塊，眼壓未查，房角鏡也未檢查。

There was no further trouble until 8 years later, when she developed acute glaucoma in the same eye. After miotic treatment, an iridectomy was performed. Later, prophylactic iridectomy was performed on the opposite eye at the patient’s request. IOP remained normal thereafter in both eyes.

此后一直無特殊，直至8年后，右眼閉青急性發(fā)作，縮瞳后予以虹膜周切，其后對側(cè)眼預(yù)防性周切。此后雙眼眼壓正常。

Here is a classic picture of an eye that had acute angleclosure glaucoma. The iritis was undoubtedly sequelae from acute angle-closure glaucoma, and the initial treatment by mydriasis, as sometimes occurs, broke the first attack.

這是急閉的典型經(jīng)過，所謂虹膜炎其實是急閉發(fā)作所致，當(dāng)初的散瞳治療，消除了瞳孔阻滯，散瞳能夠有效緩解急閉并非少見。

（本文作者：郝曉軍，尖峰眼科浦南臨床基地）