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如何提高青光眼知晓率——美国托马斯杰斐逊大学Marlene R.Moster教授专访

2013-7-2 10:42| 发布者: Sonia| 查看: 4089| 评论: 0 |来自: 国际眼科时讯

摘要:Dr. Moster, when you have a choice among therapies; drug, laser, surgery; which do you usually go to in your practice?
    <International Ophthalmology Times>:Dr. Moster, when you have a choice among therapies; drug, laser, surgery; which do you usually go to in your practice?
  Dr. Moster:When I’m confronted with someone who needs glaucoma treatment, we often start with medications, then move to laser, and of course after all the conservative modalities have been tried, we then move on to surgery. There are occasional patients who would benefit from laser first. Those are patients who are very well informed, younger patients, patients with pseudoexfoliation, perhaps patients with pigmentary dispersion syndrome, and more importantly patients who I do believe would be noncompliant or have difficulty paying for medication. In that select group, I recommend laser first. I explain it to them, explain why the laser might benefit cutting out the highs and lows of the intraocular pressure spikes and ultimately control their pressure better than someone who was given medication, but didn’t actually take it because it doesn’t well and the bottle has to get in the eye.
  《国际眼科时讯》:Moster教授,药物、激光和手术三种治疗手段,您在临床中通常如何选择?
  Dr. Moster:对于需要干预治疗的青光眼患者,一般起始选择药物治疗,然后选择激光,当然所有保守的治疗方式采用之后,我们再考虑手术。有些情况下,我们会首选激光治疗。这些特定的人群包括:充分知晓的患者、更年轻的患者、假性剥脱综合征的患者,特别是依从性差,或着无力承担药物治疗的患者。我会向他们解释,激光可能减少眼压波动,较药物治疗降眼压效果好。但因它的效果不确定,且要将镜子放入眼睛进行激光治疗,并非所有的人都接受,
  <International Ophthalmology Times>:In your opinion, what are the causes of failure in glaucoma treatment?
  Dr. Moster:There are many reasons glaucoma treatment fails, and our biggest issue is compliance. Patients who are in multiple therapies, for example, may run out of one of the therapies first and not refill the drug till all their drugs that they are taking run out because they don’t want to go to the pharmacy and perhaps spend additional co-pay more than needed. I do believe patients not using medicine is the biggest issue, not that medicine is not working. I do believe they work well. I think they work well in 80% of patients if they are used correctly. That is our biggest huddle.
  《国际眼科时讯》:您认为青光眼治疗失败的原因何在?
  Dr. Moster:原因很多,最大的问题是依从性。接受多种治疗的患者,可能会先放弃一种治疗。药用完了他们就不再用了,因为懒得去买或是要花钱。我想失败的原因是患者自行停药,而不是药物无效。我相信药物的疗效。如果使用得当,药物对80%人都是有效的。这是最大的问题。
  <International Ophthalmology Times>:In your talk, you said that it should be not only a focus on pressure, but also vision. What did you mean by that?
  Dr. Moster:I think the focus has changed. The paradigm has shifted. When I started glaucoma practice in 1984 after fellowship, we were all consumed with lowering the intraocular pressure. Unfortunately, because of our techniques at the time, vision was not upfront and center. We lowered pressure enough. The patient couldn’t see. It was basically too bad. That’s just not acceptable today.
  Today, we have a focus of getting people back into the workplace, having them resume their normal activities quickly. That for me is very high on my list of how to treat patients well. For example, if I were to operate on you, you are a busy guy, I need to get you back to work, you’re supporting your family. It’s imperative that not only is the optic nerve happy, but the patient is happy. In order to be happy, you have to see. Therefore, that is upfront and center.
  We remove the cataracts, we take care of the astigmatism. In select patients, we’ve been using toric lenses and combined with glaucoma surgery. We make sure that we understand what the limited visual potential is perhaps, make sure retina colleagues are on board if we have patients who may have early macular degeneration or may benefit from some of the anti-VEGF drugs. We have just a whole different focus now than we did before.
  《国际眼科时讯》:您说不应只关注眼压,还应关注视力。深层含义是什么?
  Dr. Moster:关注的焦点已经改变。我1984年进入临床时,我们所有的精力都花费在降低眼压上。不幸的是,限于技术局限,视力未被关注。我们虽充分减低了眼压,但患者看不见了。这在今天是不能被接受的。现在,我们让患者回去工作,使他们恢复到正常的工作。这是我工作的追求。例如,如果你到我这来看病,你非常繁忙,我要让你回去工作,因为你要养家。我们不只要控制视神经的萎缩,还要让患者心情愉悦,这要建立在看的见的基础上。因此,这才是我们工作的重心。我们摘除白内障,纠正散光。对于一些患者,我们应用托力克镜片,并行青光眼手术。我们会分析视力下降的原因,对于早期年龄相关性黄斑变性(AMD)的患者,我们会与眼底病的同事合作,应用抗血管内皮生长因子(VEGF)药物。我们现在的工作重心与以前截然不同。
  <International Ophthalmology Times>:In your talk, you were introduced as being famous for introducing to the glaucoma world the blitz anesthesia. In fact, you’ve mentioned it in your talk. Can you define that for our readers?
  Dr. Moster:Sure. Back in 1998 or until 1998, we were giving everybody a retrobulbar block and a facial block, so at the time of surgery there was no pain. However, that in my view was very barbaric. Giving anesthetic behind the eye just didn’t make sense to me. Around 1998, the cataract surgeons were using intracameral lidocaine in order to anesthetize the eye. I thought, “My gosh! Why not take that one step forward, so during glaucoma surgery, we don’t have to give a block behind the eye.”
  What we came up with was this blitz anesthesia technique. We call this the blitz because we attack the problem from all sides. We gave topical anesthesia in the form of Xylocaine jelly or TetraVisc jelly. We used a paracentesis followed by intracameral 1% unpreserved lidocaine to anesthetize the anterior segment. Then, using the same lidocaine on a 30-gauge needle, we injected under the conjunctiva and Tenon’s to blow it up such that it acts as a reservoir during most of the case, so the patient remains pain-free.
  The reasons this has such a positive effect for us is, one, now that patients are using more and more blood thinners because of various ailments—aspirin, Coumadin, platelet inhibitors—they more apt to bleed. By not having to stick a needle behind the eye where we can’t see, we remove the risk of a retrobulbar hemorrhage, and that’s huge.
  Additionally, we are able to have the patient help us at the time of surgery since they are totally anesthetized, they are comfortable, and they can help me with the closure. I would say, “Mrs. Smith, look up, look down, look to the left,” etcetera. It makes for a win-win situation. The patient really wants to help me so that their surgery turns up beautifully, and I have the additional help to have the patient look in every direction where if they had a retrobulbar block, the eye would be frozen.
  《国际眼科时讯》:您在闪电麻醉(blitz anesthesia)方面颇负盛名。您能向读者介绍一下吗?
  Dr. Moster:当然,1998以前,我们对患者进行秋后注射麻醉和面部神经阻滞麻醉来避免手术中的疼痛。然而在我看来这种办法太原始。我认为球后麻醉是无效的。1998年,白内障医生用利多卡因前房注射的方式来麻醉。我认为可以进步些,我在术中不采用球后麻醉。我们想出了闪电式麻醉技术。我们从多方面解决问题。我们应用利多卡因局部麻醉。前房穿刺后注入1%利多卡因进行眼前段麻醉。接着,再使用30G针头将利多卡因注入结膜及筋膜囊下,麻药慢慢释放,这样患者就不会感到疼痛了。既然越来越多的患者因为多种疾病应用血液稀释剂,如阿司匹林,香豆素,血小板抑制剂,他们容易出血。不采用无法直视的球后注射,我们避免了球后出血的风险。
  <International Ophthalmology Times>:In your lecture, you said in 2013 it’s no longer one size fits all. What did you mean by that?
  Dr. Moster:Years ago, we’d start with medicine, we’d move to laser, and then there would be this huge gap where if the patient not doing well enough and needed a lower pressure, they would then need a trabeculectomy, or if they were pseudophakic, for example, if they needed to. Now, there are so many more interesting modalities that we have available to us that bridge that gap.
  For example, we have the Glaukos eye stent, we have ExPRESS, we have the canaloplasty, we have Trabectome, and we have ECP. Most of these are best combined with cataract surgery; however, the ExPRESS and the canaloplasty do extremely well if they are standalone procedure. It makes sense to tailor the patient’s needs and lifestyle to the type of surgery we do.
  If we need a lower intraocular pressure, the patient is already in their ’60s, for example, they have some nuclear sclerosis, it makes sense to remove the cataract and do some type of glaucoma procedure for those patients who have mild-to-moderate glaucoma, which I termed glaucoma lite. Those patients do extremely well with these combined surgeries, any of them.
  In patients who do need a low pressure and need visual recovery faster, my procedure of choice is an ExPRESS shunt because although it’s been shown efficacious in the prospect of study of two years comparing to trabeculectomy with equal pressure lowering, the visual recovery with the ExPRESS in my clinical estimation and in clinical studies is faster. In that particular patient, an ExPRESS would be preferable.
  Then, there are people who are contact lens wearers, who have high intraocular pressures, but don’t have a lot of glaucoma yet. For example, patients with pseudoexfoliation, relatively young, pressures between 35 and 50, their nerves are still relatively healthy and they need a lower pressure. A canaloplasty is perfect surgery for them because it does not leave the patient with a superior blood. They can wear their contact lenses. The pressure comes down, not very low, but certainly low enough for them. That would be a win-win situation.
  So now, there’s no longer one size fits all, you have to tailor the procedure to the patients’ needs. There are amounts of glaucoma, what the eye looks like, and ultimately where they are on the visual spectrum.
  《国际眼科时讯》:您在演讲中为什么说2013年不再是一个一种方法放之四海而皆准的年代?
  Dr. Moster:多年前,我们初始选择药物,然后是激光,如果患者的眼压还是不理想,将接受小梁切除术,白内障摘除术。这与现在有很大的差别。现在我们有Glaukos eye stent、ExPRESS、Schlemm管成形术、小梁切开术和ECP。这些手术都可以联合白内障手术。单纯行ExPRESS和Schlemm管成形术的效果是非常好的。选择手术方式时需要结合患者的需求和生活方式。如果患者已经60多岁了,青光眼早期或中期,需要把眼压降的再低些,晶状体的核已经硬化了,就有必要在抗青光眼手术的同时摘除白内障。这样的患者经过青白联合后效果都很好。
  对需要快速降眼压,恢复视力的患者,我会选择ExPRESS引流器植入术。虽然一项小梁切除术和ExPRESS引流器植入术随访2年后降眼压效果相同,我在临床上发现后者视力恢复更快。因此对于特殊的病例,我会选择ExPRESS。
  还有一些人佩戴隐形眼镜,眼压高,但尚未出现视神经或视功能的改变。比如假性剥脱综合征的患者,相对年轻,眼压35~50 mm Hg,视神经还相对比较健康,需要降眼压。黏小管成形术是不错的选择,因为这种术式不需要上方的滤过泡引流。这样他们可以继续佩戴隐形眼镜。眼压虽然降低不算太低,但对患者来说足矣。这可以称为一种双赢的策略。
  因此当今,并非一种方法就能够应对各种病情。应当权衡手术的利弊与患者的需求。包括青光眼的类型,眼部的情况,以及视功能情况。
  <International Ophthalmology Times>:You ended your talk looking into the future. You think a lot of nanotechnology is going to drive glaucoma therapy.
  Dr. Moster:I’m very certain that that will come to be within the next 5 to 10 years. I do believe that smaller and smaller is going to be better and better. We will be able to conquer the holy grail of understanding pressure control eventually by being able to place a sensor in the eye and monitor what is going on in real-time.
  For example, we are currently clueless as to what happens to the intraocular pressure in an individual on any given day. Does the patient have pressure spikes? What happens when they exercise? What happens when they sleep? What happens when they change position? What happens to the intraocular pressure? We don’t know.
  We will eventually be able to have automatic sensing every five minutes with early-on capsular tension ring where all the electronics are embedded within, so the surgeon will take out the cataract, put in a sensor, and then be able from an outside source to collect all the data via the internet to whatever device the doctor chooses. The patient will need to recharge the sensor and will be able to do so by walking pass a wireless charger, for example, by the bedside, where it will download the data once every 48 hours and recharge and reprogram the sensor within the eye in one second.
  It will be incredibly fast, incredibly easy, have no downsides for the patient, and they will be able to totally have a normal life without thinking about this. Yet, we will understand the mechanism of glaucoma.
  《国际眼科时讯》:最后您对未来展望。您认为纳米技术将主宰青光眼的治疗。
  Dr. Moster:我确信这就是未来5~10年的事。越小越好。我们将通过眼内植入传感器实时监测来揭开眼压的神秘面纱,从而设法控制眼压。比如,我们无从知道个体眼压的变化。眼压有没有浪涌?是否受运动影响?睡眠时的改变?体位改变是又有什么变化?我们无从知晓。
  最终我们能够每5分钟就自动感受到信息,传感器是一个张力环,所有的电子零件嵌入其中。这样术者能够摘除晶体,放入感受器(张力环),接着就能按着自己的需要通过网络在体外搜集数据。患者可以给传感器无线充电,比如在床边就可以操作,每48小时就下载数据,给传感器充电并重调程序。速度惊人,且操作简易,对患者无不利影响,完全正常生活。届时,我们就能弄清楚青光眼的机制了。
  <International Ophthalmology Times>:As World Glaucoma Week approaches, I’d like to hear your opinion on what is the best way to raise glaucoma awareness?
  Dr. Moster:I believe the best way to raise glaucoma awareness is to make the patient aware that this is a genetic disease. I often say to the patient—come Thanksgiving, come the summer giant barbecue for the family—that someone has to stand up and say, “We have glaucoma in our family. It has a 20% penetrance. Everybody has to get their eyes checked because if this is detected early, nobody will go blind. I have every interest in getting you checked because I love you all.”
  I myself have serious glaucoma because that’s what I do. I take care of pretty advanced glaucoma. So the patients who come to see me, all have the real deal, and they can convey that this is something that everyone in that room should do. It’s worked out very very well. Come all the big holidays when families get together, the word is spread, and I do believe that’s the one way we can make people aware they understand what glaucoma is because the patient who sees me and who has the disease understands this disease, I make sure of it, so they are able to convey that to their relatives.
  《国际眼科时讯》:青光眼周就要到了,您认为提高青光眼知晓率最好途径是什么呢?
  Dr. Moster:我认为提高青光眼知晓率最好的办法就是让患者知道这是一种基因病。我经常对患者说在聚会的场合如感恩节,夏季家庭烧烤聚会,他们应该勇敢的说出自己家中有青光眼家族史。其外显率为20%。每个人都应当做眼科检查,因为早期诊断的话,青光眼是不会致盲的。因为我关心你们,所以我希望你们都做眼科检查。
  我本人非常了解青光眼,因为这是我的工作。我有一些非常严重的青光眼患者。当患者就诊时,我会向他们宣传青光眼的知识,这样他们就会将这些知识传达给其他人,而且他们认为每个人都应当这么做。效果非常好。每当重大节日家庭聚会时,大家就会谈论青光眼,这是让大家了解青光眼的途径之一,因为就诊的青光眼患者非常了解青光眼,我向他们讲述青光眼,这样他们会在说给亲戚朋友听。

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