调节和聚散功能异常的诊断和处理

调节和聚散功能异常

临床分析与处理

温州医学院眼视光学院姜俭2024/3/31eyehospitalofWMU调节和聚散功能异常的临床分析非老视性调节障碍聚散系统障碍2024/3/34eyehospitalofWMU非老视性调节障碍调节功能的测量调节灵活度调节幅度调节滞后相对调节调节异常诊断调节不足调节灵活度不良调节疲劳调节过度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.调节不足临床表现视物模糊，近距明显头痛眼酸胀阅读困难容易疲劳和想睡觉长时间阅读记忆力下降逃避学习2024/3/318eyehospitalofWMU调节不足检查结果临床检查低调节幅度调节灵活度负片检查速度慢（单眼和双眼）正相对调节低调节滞后比较大调节不足处理原则处理目的：消除疲劳症状，改进调节能力推进法测量值小于公式最小期望值：正镜附加视觉训练2024/3/320eyehospitalofWMU调节灵活度不良临床表现：由远看近或者由近看远，视物模糊头痛眼酸胀阅读困难疲劳和容易睡觉学习逃避2024/3/321eyehospitalofWMU调节灵活度不良检查发现：调节灵活度明显下降（单眼）NRA/PRA有可能下降调节灵活度下降（双眼）调节灵活度不良处理：屈光不正的矫正视觉训练（调节摆动法）不建议给予正镜附加治疗，效果不明显调节疲劳临床表现：阅读初视力正常，随着时间的延长，视力逐渐下降检查发现：持续测量调节幅度和调节灵活度均下降；调节滞后持续近距离工作后较前增加处理：视觉训练或者正镜附加2024/3/324eyehospitalofWMU调节过度临床表现：阅读困难，模糊或视觉疲劳检查发现：调节幅度正常；调节灵活度正镜速度减慢；调节超前；处理：视觉训练2024/3/325eyehospitalofWMU第二节聚散系统障碍2024/3/326eyehospitalofWMU聚散功能的检测集合幅度（NPC）隐斜测量聚散力测量（BI/BO）聚散灵活度Performedatadistanceof40cmwithatargetof20/30.Mostnormalpatientscancyclebetweentheseprims15/minute.12ΔBase-Outand3ΔBase-InAC/A的测量遮盖试验WORTH4DOT2024/3/327eyehospitalofWMU聚散障碍类型及其处理原则会聚不足会聚过度散开不足散开过度单纯性外隐斜单纯性内隐斜融像性聚散减低假性会聚不足2024/3/328eyehospitalofWMUVergenceAnomaliesConvergenceInsufficiencyConvergenceExcessFusionalVergenceDysfunctionPseudo-ConvergenceInsufficiencyDivergenceExcessDivergenceInsufficiencyBasicExophoriaBasicEsophoria会聚不足特征：远距隐斜正常，近距高度外隐斜近距正相对会聚（PRC）降低会聚近点（NPC）降低低AC/A调节参数测量结果一般正常治疗原则视觉训练（首选措施）对于外隐斜，适用于sheard法则患者不配合或无效，可予棱镜处方2024/3/330eyehospitalofWMU法则Sheard准则：融像性储备至少应为隐斜量的两倍（多用外隐斜）1：1准则：BI的恢复值至少应该等同内隐斜Percival准则：需求线必须通过由双眼单视清晰区中间三分之一宽度与零到3.0D之间范围构成的舒适区2024/3/331eyehospitalofWMU会聚过度特征:远距正常，近距内隐斜负相对会聚低（NRC）计算性AC/A高症状短时间阅读后出现眼部不适和头痛与近距离工作相关的视力模糊或者复像临床处理：近距近附加镜片（高AC/A使用效果佳）视觉训练（效果相对差）2024/3/332eyehospitalofWMU散开不足特征：远距内隐斜近距眼位正常AC/A低症状常见症状有远距复像、头疼和眼部不适临床处理：BO棱镜（首选），仅仅用于远距离或者全时佩戴视觉训练增加负融像性聚散功能2024/3/333eyehospitalofWMU散开过度特征远距高度外隐斜，近距隐斜正常范围刺激性AC/A高常见症状远距复视和视觉疲劳临床处理：首选视觉训练效果佳远距离BI棱镜和近距离球镜附加2024/3/334eyehospitalofWMU单纯性外隐斜特征：远近隐斜均大于正常范围的外隐斜AC/A基本在正常范围内症状与用眼有关的眼部紧张或者头疼与用眼有关的视力模糊或者复像临床处理：视觉训练是首选方法可以考虑使用BI棱镜2024/3/335eyehospitalofWMU单纯性内隐斜特征：远近内隐斜均大于正常内隐斜范围AC/A大致正常症状近点视疲劳最常见远距离或者近距离偶尔视力模糊或者复像临床处理首选BO棱镜治疗视觉训练远视性屈光不正需要完全矫正2024/3/336eyehospitalofWMU融像性聚散减低特征：远近分离性隐斜均正常BOBI融像性聚散范围均低于正常调节幅度和调节滞后正常范围AC/A正常症状与阅读或近距离工作有关临床处理矫正屈光不正和垂直偏斜视觉训练增加正负融像性聚散范围2024/3/337eyehospitalofWMU假性会聚不足特征：类同于真性会聚不足远距隐斜正常，近距高度外隐斜，正相对会聚可能低或正常，调节幅度低，调节滞后异常高实质：调节不足临床处理：近距正镜附加视觉训练增加调节功能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－老家小村日出调节和聚散功能异常的处理屈光不正正或负性附加镜棱镜视觉训练2024/3/342eyehospitalofWMU第一节屈光不正2024/3/343eyehospitalofWMU屈光不正量大小所产生的影响屈光不正类型有临床意义的量远视≥+1.50D近视≥-1.00D散光≥1.00D屈光参差≥1.00D2024/3/344eyehospitalofWMU屈光不正未矫或者欠矫欠矫和过矫导致调节功能失常诱发高量隐斜双眼不平衡,感觉融像异常减低融像能力,导致视网膜像模糊矫正屈光不正还需要考虑AC/A值有双眼视功能异常者,屈光不正应先矫正2024/3/3eyehospitalofWMU45睫状肌麻痹检影通常情况下，静态检影加自然状态下主觉验光可以确定和解决大部分屈光不正病例使用睫状肌麻痹检影要考虑：睫状肌本身的张力双眼状态：内隐斜最大正度数非显著性屈光不正量：临床上低度数屈光不正，如明确该屈光不正与眼部视觉功能问题相关，一般给予矫正。2024/3/346eyehospitalofWMU第二节正或负球性附加镜2024/3/347eyehospitalofWMU提示使用正附加镜AC/A比率高低屈光不正远视近视近隐斜内隐斜外隐斜负相对调节低PRA低NRA正相对调节近距BO正常-高低调节反应高低调节幅度低高调节灵活度负符号不通过正符号不通过2024/3/348eyehospitalofWMU使用正镜附加不宜使用正镜附加提示使用负附加镜测试使用负附加镜不宜使用负附加镜AC/A高低CA/C高低隐斜外隐斜内隐斜近距BI正常-高低调节幅度正常低调节灵活度正符号不通过负符号不通过年龄低于6岁大于9岁2024/3/349eyehospitalofWMU适合选择附加镜的病例正附加镜负附加镜会聚过度高度外隐斜单纯性内隐斜发散过度调节不足持续性调节疲劳2024/3/350eyehospitalofWMU第三节棱镜2024/3/351eyehospitalofWMU棱镜的使用水平缓解棱镜垂直缓解棱镜视觉训练起始训练失败或无效后治疗棱镜2024/3/352eyehospitalofWMU水平缓解棱镜原则：先视觉训练，视觉训练无效或不宜采用时，才使用棱镜棱镜的有效性不明确用于：低AC/A聚散不足单纯内隐斜垂直隐斜2024/3/353eyehospitalofWMU

诊断首选方法次选方法

眼动异常视觉训练正附加

调节不足正附加视觉训练

调节过度视觉训练

调节疲劳视觉训练

低AC/A会聚不足视觉训练棱镜发散不足棱镜视觉训练高AC/A会聚过度附加镜视觉训练发散过度视觉训练附加镜正常AC/A单纯性内隐斜视觉训练和附加镜棱镜单纯性外隐斜视觉训练附加镜和棱镜融像性聚散异常垂直异常视觉训练

垂直隐斜棱镜视觉训练垂直缓解棱镜原则：棱镜处方应将注视视差降低到零Sheard法则既有水平又有垂直偏斜时，首先考虑对垂直隐斜进行矫正2024/3/355eyehospitalofWMU视觉训练起始BOBI可以用来训练融像性聚散力训练效果佳训练效果与依从性等各种原因相关2024/3/356eyehospitalofWMU第四节视觉训练增加正负融像性聚散增加调节幅度