調(diào)節(jié)和聚散功能異常的診斷和處理

調(diào)節(jié)和聚散功能異常

臨床分析與處理

溫州醫(yī)學(xué)院眼視光學(xué)院姜儉2024/3/31eyehospitalofWMU調(diào)節(jié)和聚散功能異常的臨床分析非老視性調(diào)節(jié)障礙聚散系統(tǒng)障礙2024/3/34eyehospitalofWMU非老視性調(diào)節(jié)障礙調(diào)節(jié)功能的測量調(diào)節(jié)靈活度調(diào)節(jié)幅度調(diào)節(jié)滯后相對調(diào)節(jié)調(diào)節(jié)異常診斷調(diào)節(jié)不足調(diào)節(jié)靈活度不良調(diào)節(jié)疲勞調(diào)節(jié)過度2024/3/35eyehospitalofWMUGeneralDiagnosticCategoriesAccommodativeDysfunctions(Duke-Elder)AccommodativeInsufficiencyIll-SustainedAccommodationAccommodativeInfacilityParalysisofAccommodationSpasmofAccommodationVsAccomExcessFromAOA“CareofpatientwithAccommodativeandVergenceDysfunctionGeneralDiagnosticCategoriesAccommodativeDysfunctionsAccommodativeInsufficiencyIll-SustainedAccommodationParalysisofAccommodationUnequalaccommodationAccommodativeInfacilitySpasmofAccommodationVsAccomExcessFromclinicalmanagementofbinocularvision2ndedition

"NOTENOUGH”“UNSURE”"TOOMUCH"

InsufficiencyInfacilityExcess

AccommodativeAnomaliesLowAmplitudeHighLagFacility:Poor–OD,OS,OUMEM&FCCNormaltolowNRA/PRAreducedFacility:poor-/+OD,OS,OUMEM&FCCLowLowNRAFacility:poor+OD,OS,OUAmplitudeofAccommodationMinuslenstoblurProcedurePhoropterbased,easytodoafterPRANorm:2Dlessthanpush-upPush-upProcedureFreespaceorphoropterNorm:18.5–0.3(age)Minimum:

15–0.25(age)AccommodativeFacilityTestingMonocularVergenceis“openlooped”BinocularImpactofvergenceCPOE3rdedpgs193-196BinocularAccommodativeFacilityTestingVectogram#9PatientwearingPolaroidglasseswith+flippersAccommodativeFacilityProcedurefor+2.00flippersMonocularDifferentinstructionalsetsforkidsandadultsNorms:Children6yo 5.5cpm+2.5cpm7yo 6.5cpm+2.0cpm8-12 7.0cpm+2.5cpmAdults13-30 11.0cpm+5.0cpmAccommodativeFacilityProcedurefor+2.00flippersMonocularDifferentinstructionalsetsforkidsandadultsNormsTest(+2.00)ExpectedFindingStandardDevMAF-KidsCPM=cycles/minuteAge6-76CPM+2.5CPMAge8-127CPM+2.5CPMMAF-AdultsAge13-3011CPM+5CPM>30N/A2024/3/3eyehospitalofWMU13AccommodativeFacilityProcedurefor+2.00flippersBinocularVecto#9,vsCEPOvsRockcardNormsBAF:binocularaccommodativefacilityTest(+2.00)ExpectedFindingStandardDevBAF-KidsAge6-73CPM+2.5CPMAge8-125CPM+2.5CPMBAF-AdultsUseAmpscaledtesting2024/3/3eyehospitalofWMU14AccommodativeFacilityOtherobservationsandrecordingValuableinDxandTxSectoclearminusandplusVScpmIsthereadifferencebetweenthetimeoftransitionbetween–to+or+to-?SustainingabilityLagofAccommodationFusedCrossCyclinderNottRetinscopyMonocularEstimateMethodRetinoscopyOthernearpoint/dynamicretinoscopytechniques:BellandBookNRA/PRAThetargetmustbeanaccommodativestimulusPlus/minuslensesareaddedbinocularlyasthepatientfixatesat40cmPlus/minuslensesareaddedandthepatientisinstructedtoreportwhenthetargetbecomesblurredTheendpointisreachedwhenthelensesinfrontoftheeyesprovidethefirstsustainedblur.調(diào)節(jié)不足臨床表現(xiàn)視物模糊，近距明顯頭痛眼酸脹閱讀困難容易疲勞和想睡覺長時間閱讀記憶力下降逃避學(xué)習(xí)2024/3/318eyehospitalofWMU調(diào)節(jié)不足檢查結(jié)果臨床檢查低調(diào)節(jié)幅度調(diào)節(jié)靈活度負片檢查速度慢（單眼和雙眼）正相對調(diào)節(jié)低調(diào)節(jié)滯后比較大調(diào)節(jié)不足處理原則處理目的：消除疲勞癥狀，改進調(diào)節(jié)能力推進法測量值小于公式最小期望值：正鏡附加視覺訓(xùn)練2024/3/320eyehospitalofWMU調(diào)節(jié)靈活度不良臨床表現(xiàn)：由遠看近或者由近看遠，視物模糊頭痛眼酸脹閱讀困難疲勞和容易睡覺學(xué)習(xí)逃避2024/3/321eyehospitalofWMU調(diào)節(jié)靈活度不良檢查發(fā)現(xiàn)：調(diào)節(jié)靈活度明顯下降（單眼）NRA/PRA有可能下降調(diào)節(jié)靈活度下降（雙眼）調(diào)節(jié)靈活度不良處理：屈光不正的矯正視覺訓(xùn)練（調(diào)節(jié)擺動法）不建議給予正鏡附加治療，效果不明顯調(diào)節(jié)疲勞臨床表現(xiàn)：閱讀初視力正常，隨著時間的延長，視力逐漸下降檢查發(fā)現(xiàn)：持續(xù)測量調(diào)節(jié)幅度和調(diào)節(jié)靈活度均下降；調(diào)節(jié)滯后持續(xù)近距離工作后較前增加處理：視覺訓(xùn)練或者正鏡附加2024/3/324eyehospitalofWMU調(diào)節(jié)過度臨床表現(xiàn)：閱讀困難，模糊或視覺疲勞檢查發(fā)現(xiàn)：調(diào)節(jié)幅度正常；調(diào)節(jié)靈活度正鏡速度減慢；調(diào)節(jié)超前；處理：視覺訓(xùn)練2024/3/325eyehospitalofWMU第二節(jié)聚散系統(tǒng)障礙2024/3/326eyehospitalofWMU聚散功能的檢測集合幅度（NPC）隱斜測量聚散力測量（BI/BO）聚散靈活度Performedatadistanceof40cmwithatargetof20/30.Mostnormalpatientscancyclebetweentheseprims15/minute.12ΔBase-Outand3ΔBase-InAC/A的測量遮蓋試驗WORTH4DOT2024/3/327eyehospitalofWMU聚散障礙類型及其處理原則會聚不足會聚過度散開不足散開過度單純性外隱斜單純性內(nèi)隱斜融像性聚散減低假性會聚不足2024/3/328eyehospitalofWMUVergenceAnomaliesConvergenceInsufficiencyConvergenceExcessFusionalVergenceDysfunctionPseudo-ConvergenceInsufficiencyDivergenceExcessDivergenceInsufficiencyBasicExophoriaBasicEsophoria會聚不足特征：遠距隱斜正常，近距高度外隱斜近距正相對會聚（PRC）降低會聚近點（NPC）降低低AC/A調(diào)節(jié)參數(shù)測量結(jié)果一般正常治療原則視覺訓(xùn)練（首選措施）對于外隱斜，適用于sheard法則患者不配合或無效，可予棱鏡處方2024/3/330eyehospitalofWMU法則Sheard準則：融像性儲備至少應(yīng)為隱斜量的兩倍（多用外隱斜）1：1準則：BI的恢復(fù)值至少應(yīng)該等同內(nèi)隱斜Percival準則：需求線必須通過由雙眼單視清晰區(qū)中間三分之一寬度與零到3.0D之間范圍構(gòu)成的舒適區(qū)2024/3/331eyehospitalofWMU會聚過度特征:遠距正常，近距內(nèi)隱斜負相對會聚低（NRC）計算性AC/A高癥狀短時間閱讀后出現(xiàn)眼部不適和頭痛與近距離工作相關(guān)的視力模糊或者復(fù)像臨床處理：近距近附加鏡片（高AC/A使用效果佳）視覺訓(xùn)練（效果相對差）2024/3/332eyehospitalofWMU散開不足特征：遠距內(nèi)隱斜近距眼位正常AC/A低癥狀常見癥狀有遠距復(fù)像、頭疼和眼部不適臨床處理：BO棱鏡（首選），僅僅用于遠距離或者全時佩戴視覺訓(xùn)練增加負融像性聚散功能2024/3/333eyehospitalofWMU散開過度特征遠距高度外隱斜，近距隱斜正常范圍刺激性AC/A高常見癥狀遠距復(fù)視和視覺疲勞臨床處理：首選視覺訓(xùn)練效果佳遠距離BI棱鏡和近距離球鏡附加2024/3/334eyehospitalofWMU單純性外隱斜特征：遠近隱斜均大于正常范圍的外隱斜AC/A基本在正常范圍內(nèi)癥狀與用眼有關(guān)的眼部緊張或者頭疼與用眼有關(guān)的視力模糊或者復(fù)像臨床處理：視覺訓(xùn)練是首選方法可以考慮使用BI棱鏡2024/3/335eyehospitalofWMU單純性內(nèi)隱斜特征：遠近內(nèi)隱斜均大于正常內(nèi)隱斜范圍AC/A大致正常癥狀近點視疲勞最常見遠距離或者近距離偶爾視力模糊或者復(fù)像臨床處理首選BO棱鏡治療視覺訓(xùn)練遠視性屈光不正需要完全矯正2024/3/336eyehospitalofWMU融像性聚散減低特征：遠近分離性隱斜均正常BOBI融像性聚散范圍均低于正常調(diào)節(jié)幅度和調(diào)節(jié)滯后正常范圍AC/A正常癥狀與閱讀或近距離工作有關(guān)臨床處理矯正屈光不正和垂直偏斜視覺訓(xùn)練增加正負融像性聚散范圍2024/3/337eyehospitalofWMU假性會聚不足特征：類同于真性會聚不足遠距隱斜正常，近距高度外隱斜，正相對會聚可能低或正常，調(diào)節(jié)幅度低，調(diào)節(jié)滯后異常高實質(zhì)：調(diào)節(jié)不足臨床處理：近距正鏡附加視覺訓(xùn)練增加調(diào)節(jié)功能2024/3/338eyehospitalofWMUIsphoriagreateratdistanceornear?N>DConvergenceproblemD>NDivergenceproblemD=NBasicEsoLowAC/AExoHighAC/AEsoExoEsoHighAC/AExoLowAC/ACECIDIBasicEsoDEBasicExoDuane-WhiteClassification2024/3/3eyehospitalofWMU39

Convergence

“NotEnough”“Unsure”“TooMuch”

VergenceAnomalies

ReducedNPCExo’>ExoPoorBO’ConstrictedBO&BIConstrictedNRA/PRANPCTTNEso’>EsoPoorBIInsufficiencyInfacilityFusionalVergenceDysfunctionExcess2014年春－老家小村日出調(diào)節(jié)和聚散功能異常的處理屈光不正正或負性附加鏡棱鏡視覺訓(xùn)練2024/3/342eyehospitalofWMU第一節(jié)屈光不正2024/3/343eyehospitalofWMU屈光不正量大小所產(chǎn)生的影響屈光不正類型有臨床意義的量遠視≥+1.50D近視≥-1.00D散光≥1.00D屈光參差≥1.00D2024/3/344eyehospitalofWMU屈光不正未矯或者欠矯欠矯和過矯導(dǎo)致調(diào)節(jié)功能失常誘發(fā)高量隱斜雙眼不平衡,感覺融像異常減低融像能力,導(dǎo)致視網(wǎng)膜像模糊矯正屈光不正還需要考慮AC/A值有雙眼視功能異常者,屈光不正應(yīng)先矯正2024/3/3eyehospitalofWMU45睫狀肌麻痹檢影通常情況下，靜態(tài)檢影加自然狀態(tài)下主覺驗光可以確定和解決大部分屈光不正病例使用睫狀肌麻痹檢影要考慮：睫狀肌本身的張力雙眼狀態(tài)：內(nèi)隱斜最大正度數(shù)非顯著性屈光不正量：臨床上低度數(shù)屈光不正，如明確該屈光不正與眼部視覺功能問題相關(guān)，一般給予矯正。2024/3/346eyehospitalofWMU第二節(jié)正或負球性附加鏡2024/3/347eyehospitalofWMU提示使用正附加鏡AC/A比率高低屈光不正遠視近視近隱斜內(nèi)隱斜外隱斜負相對調(diào)節(jié)低PRA低NRA正相對調(diào)節(jié)近距BO正常-高低調(diào)節(jié)反應(yīng)高低調(diào)節(jié)幅度低高調(diào)節(jié)靈活度負符號不通過正符號不通過2024/3/348eyehospitalofWMU使用正鏡附加不宜使用正鏡附加提示使用負附加鏡測試使用負附加鏡不宜使用負附加鏡AC/A高低CA/C高低隱斜外隱斜內(nèi)隱斜近距BI正常-高低調(diào)節(jié)幅度正常低調(diào)節(jié)靈活度正符號不通過負符號不通過年齡低于6歲大于9歲2024/3/349eyehospitalofWMU適合選擇附加鏡的病例正附加鏡負附加鏡會聚過度高度外隱斜單純性內(nèi)隱斜發(fā)散過度調(diào)節(jié)不足持續(xù)性調(diào)節(jié)疲勞2024/3/350eyehospitalofWMU第三節(jié)棱鏡2024/3/351eyehospitalofWMU棱鏡的使用水平緩解棱鏡垂直緩解棱鏡視覺訓(xùn)練起始訓(xùn)練失敗或無效后治療棱鏡2024/3/352eyehospitalofWMU水平緩解棱鏡原則：先視覺訓(xùn)練，視覺訓(xùn)練無效或不宜采用時，才使用棱鏡棱鏡的有效性不明確用于：低AC/A聚散不足單純內(nèi)隱斜垂直隱斜2024/3/353eyehospitalofWMU

診斷首選方法次選方法

眼動異常視覺訓(xùn)練正附加

調(diào)節(jié)不足正附加視覺訓(xùn)練

調(diào)節(jié)過度視覺訓(xùn)練

調(diào)節(jié)疲勞視覺訓(xùn)練

低AC/A會聚不足視覺訓(xùn)練棱鏡發(fā)散不足棱鏡視覺訓(xùn)練高AC/A會聚過度附加鏡視覺訓(xùn)練發(fā)散過度視覺訓(xùn)練附加鏡正常AC/A單純性內(nèi)隱斜視覺訓(xùn)練和附加鏡棱鏡單純性外隱斜視覺訓(xùn)練附加鏡和棱鏡融像性聚散異常垂直異常視覺訓(xùn)練

垂直隱斜棱鏡視覺訓(xùn)練垂直緩解棱鏡原則：棱鏡處方應(yīng)將注視視差降低到零Sheard法則既有水平又有垂直偏斜時，首先考慮對垂直隱斜進行矯正2024/3/355eyehospitalofWMU視覺訓(xùn)練起始BOBI可以用來訓(xùn)練融像性聚散力訓(xùn)練效果佳訓(xùn)練效果與依從性等各種原因相關(guān)2024/3/356eyehospitalofWMU第四節(jié)視覺訓(xùn)練增加正負融像性聚散增加調(diào)節(jié)幅度