如果发生黄斑变性,会有哪些表现呢?医学上,黄斑变性分为萎缩性和渗出性两种类型,通俗的讲,可以分为干性黄斑变性和湿性黄斑变性。干性黄斑变性是由于视细胞代谢产物堆积在视网膜下,导致黄斑区萎缩,视力下降;而湿性黄斑变性的危害更为严重,它是由于原本没有血管的正常视网膜区域,长出了异常的新生血管,而这种新生血管非常脆弱,极易发生破裂、渗漏和出血,从而导致我们的黄斑功能严重受损,出现眼前黑影、看东西变形扭曲、视物模糊等症状。稍感安慰的是,临床上只有大约10%的黄斑变性属于湿性黄斑变性。不过,干性黄斑变性可能逐渐转化为湿性黄斑变性,而如果不及时治疗,大约85%的湿性黄斑变性患者最终可能失明。因此,尽早发现黄斑变性,尽早治疗对于延缓视力下降甚至提高视力都是非常重要的。我们建议:对于55岁以上人群应该每年检查一次眼底,OCT和眼底造影检查可以更准确的发现早期病变,确定黄斑变性的类型,如果发现有黄斑变性,就应密切随诊,针对黄斑变性的类型,及时做出正确的治疗方案,以便更好的保存视力。那么,黄斑变性应当怎样治疗呢?对于干性黄斑变性,可以口服一些抗氧化维生素和补充微量元素,比如维生素C、叶黄素、β胡萝卜素等,尽早戒烟,保持低脂、低胆固醇饮食,多食蔬菜水果,包括:胡萝卜、玉米、南瓜、小胡瓜、黄瓜、芹菜、菠菜、甘薯、枸杞、猕猴桃、红葡萄、香瓜、干杏等。而湿性黄斑变性往往病情发展更为凶猛,危害更大,仅仅补充抗氧化剂或者叶黄素无法阻止病变发展,往不能解决问题。由于湿性黄斑变性主要问题在于出现异常的新生血管,破裂出血,甚至形成斑痕,影响视力。活血化瘀的药同样不能解决新生血管的问题,甚至可能加重眼底出血。目前世界上治疗湿性黄斑变性的特效药是新生血管抑制剂,这种药通过眼内注射,可以有效抑制新生血管,合理的使用这种方法治疗,可以有效的控制病情发展,挽救视力。对新生血管抑制剂而言,尽早发现新生血管尽早治疗,效果更好。总之,对于黄斑变性的预防治疗,关键在于保持良好的生活习惯、健康合理的饮食结构、定期的眼底检查,一旦确诊黄斑变性,应当尽早分型,并根据医生的指导,尽早制定有针对性的治疗方案,最大程度的保存有用的视功能。本文系林思勇医生授权好大夫在线(www.haodf.com)发布,未经授权请勿转载。
1、什么是白内障? 任何原因引起的晶状体混着。2、为什么会得白内障?由多种原因引起,如老化、遗传、代谢障碍异常、外伤、辐射、中毒、局部营养障碍等,可引起晶状体囊膜损伤,丧失屏障作用,或导致晶状体代谢紊乱,使晶状体蛋白变性,形成混浊。我们常说的一般指老年性白内障。3、得了白内障后会有什么感觉?眼前黑影、无痛性渐进性视力下降、单眼复视、眩光等。4、白内障能不能预防,有没有药物可以治疗?老年性白内障好比人老长白头发一样,故目前尚无疗效肯定的药物,故白内障的治疗以手术治疗为主。5、什么时候该手术了?视功能不能满足日常生活的需要,而且白内障手术有理由提供改善视力的可能时,也适用于晶体混浊妨碍眼后节疾病的治疗时,晶状体引起的炎症、房角关闭和药物不能控制的开角型青光眼。6、手术方式? 超声乳化手术。 我院最近引进飞秒白内障手术,更安全、精准,实现无刀手术。7、选择什么样的晶体好?人工晶体的选择根据患者的经济条件、眼部的病情等综合因素制定,并不是便宜的就不好,也不是最贵的就适合。传统的球面晶体在成像时会产生球面差、色差,而非球面晶体设计的改善,可使物像更清晰。单焦人工晶体只能看清楚一个距离的物体,而多焦人工晶体可以满足患者的全程视力。此外患者眼底情况不好可选择防蓝光晶体,有散光可选择散光晶体等等。8、手术花多少钱? 根据医院的具体情况而定。9、患者入院前准备:心理准备、控制好血糖、血压、控制呼吸系统疾病、女性患者避开经期、了解白内障相关知识。家属的准备工作:家属要对患者的病情及眼部的基础条件有一个清楚的认知——患者之间不要互相比较,对手术有客观正确的认识,有合理的期望值,充分信任手术医师。
黄斑孔如何治疗?目前没有任何药物能够有效的治疗黄斑裂孔!特发性黄斑裂孔多数需要手术治疗。最为早期的黄斑裂孔,也就是我们医学上所归类的1期黄斑裂孔,可能自行愈合,其他绝大部分黄斑裂孔需要手术治疗,促使裂孔愈合,改善视力。目前黄斑裂孔的手术已经广泛使用微创玻璃体手术,接受25G或者更精细的27G微创手术,手术创伤很小,恢复更快。黄斑裂孔手术相关问题1.黄斑裂孔术后需要在眼球内充填气体,促进裂孔愈合,因此,手术需要患者俯卧位(趴着睡觉)大约3-7天,有利于裂孔愈合。2.黄斑裂孔手术需要多长时间?需要麻醉吗?黄斑裂孔进行微创玻璃体手术,大约需要20-30分钟,局部麻醉即可,手术中没有痛苦,甚至可以和手术医生交流。3.手术费用?住院多长时间?微创玻璃体手术除医保报销以外,患者本人需要额外负担约5000元左右。住院时间大约3-5天即可
人民网. 专访医院业务院长 林思勇
Tips for a Successful ResidencyBy John Kitchens, MD What do I know about being a good resident?That is a great question that I can answer in three words: I was one. The best advice comes from people with experience. As a former resident, fellow, and chief resident, I have been through enough to at least come up with 5 suggestions to getting the most out of residency. I was an ophthalmology resident at the University of Iowa from 2000 through 2003. During this time I had the opportunity to learn from some of the best “teachers” in ophthalmology. I made the most of my time in Iowa City and that earned me the opportunity to complete a retina fellowship followed by a chief residency at Bascom Palmer in Miami. As a chief resident, I had the chance to work directly with some of the best residents in the country. This led me to a position in private practice with the Retina Associates of Kentucky, in Lexington, where we train a vitreoretinal fellow each year. Through these experiences, I have learned a lot about training and what can help make the most out of the great opportunity to train in ophthalmology. Pearl #1: Read as much as possible Dr. Ed Norton, the “father” of Bascom Palmer and who was a brilliant ophthalmologist and a respected chairman, was renowned for his knowledge of all aspects of ophthalmology. Dr. Norton’s secret was that he read something about ophthalmology every night (a chapter or a paper). Many times, medical students will lose their drive to read and learn after their first two years of medical school. Among the factors that lead to this include: an expanded work-load (e.g., rounds, clinics, etc), the fact that so much learning occurs “on the job”, and that many students begin to have families that take up much of their free time. In addition, the internship year does not lend itself to reading as interns going into ophthalmology have little motivation to read during their non-eye rotations. Also, time pressures during internship make it a difficult time to read. Additionally, it is no small task to continue to read during the ophthalmology residency. Long days in clinic and the sharp learning curve can discourage even the best residents. The most important thing to remember is that you only have three years to build the basis of your entire career. These fundamentals will be what you build on for the rest of your life. Don’t let a day go by that you don’t read something about ophthalmology, whether it is an article or a chapter or something online. “What should I read?” is an excellent question. I recommend three types of reading: the American Academy of Ophthalmology’s basic science series (BCSC), journals, articles and book chapters about your patients. The basic science series should be read each year and requires more “long-term” planning. You should try to get through one book per month. I tried to correlate and read the book with the type of rotation that I was on. It is best to put aside one hour a day to read from the BCSC. Reading journals will establish the fundamentals that will keep you current throughout your career. It will also show your faculty that you are interested in staying current and have the discipline required to become an outstanding ophthalmologist. It is best to try and read the “Big 3”: Ophthalmology, American Journal of Ophthalmology, and Archives of Ophthalmology. In addition, when you are on a certain rotation, try to read the journal(s) specific to that rotation. One major advance that has made journal reading much easier is RSS feeds. An RSS feed allows you to find out when new articles or volumes of journals are available. It can be very hard to keep up with all of these journals, all of the time; hence, I would often read the abstracts and spend more time focusing on articles I found valuable. Reading on your patients will not only help your patients, but will also help you learn and remember the diseases you are studying. If you see an interesting case of an unusual diagnosis, then read on it. You will never forget the specifics about a disease if you have seen it first hand. Pearl #2: Prepare to be overwhelmedThis is especially true for first year ophthalmology residents. You enter into a new field knowing nothing about the examination or the diseases you are about to encounter. In many ways, medical school and internship does little to prepare you to survive your first few months of an eye residency.You can prepare yourself in several different ways. The first way is to spend time during your internship reading about ophthalmology. It is great if you can get your BCSC series during your internship and read it during that year. Many programs will give you a copy of the BCSC only once you start your residency. It is worth calling them to see if they can provide it to you in advance. If you cannot get the BCSC, the next best option is to read a text with good photos and basic descriptions of diseases. Kanski has written an excellent text that I read during my internship: Clinical Ophthalmology: A Systematic Approach (Hardcover). It has great photos of almost all the conditions you are likely to encounter in residency.Another book I highly recommend is Practical Ophthalmology: A Manual for Beginning Residents(Paperback) by Dr. Fred Wilson. This book discusses the fundamentals of examination techniques (e.g., refraction, applanation, slit lamp examination, etc.). Many residency programs will supply this book to you at the initiation of your residency. It would be worthwhile contacting your residency program director to see if you could obtain a copy of this book prior to starting residency.It is important to understand that the first few months are very overwhelming and that with time, you will learn the fundamentals of the examination and things will get much easier. Also realize that your fellow residents are going through the same process. Enjoy and embrace the many things you are about to learn ( e.g., refraction, indirect ophthalmoscopy, cataract surgery, etc.). Pearl #3: Be a good assistantDr. Wallace Alward, a glaucoma specialist at the University of Iowa, gave me a valuable “pearl of wisdom” early on during my second year of residency. He told me that he could often determine the best resident surgeons by observing how they assisted with surgery early on in their careers. Having worked with residents and fellows, I can now appreciate what he meant with this comment.A good assistant in surgery will have an in-depth knowledge of the surgery being performed. A resident who demonstrates that they understand every step in the procedure, is much more likely to get the chance to operate than one who “just shows up”. Anticipation of the next step, having suture or scissors ready to cut, keeping the cornea well lubricated, and holding the eye in proper place are all ways that you can show that you have a good understanding of how to approach the surgery. Being a good surgeon is not about how steady your hands are, it is about being able to anticipate and avoid complications. It is also about knowing how to deal with complications when they occur. In my mind, being a good surgeon is similar to being a good airplane pilot. Any qualified pilot can take off, fly a route, and land; the difference between an average pilot and a great one comes out when there are problems. The great pilot is more likely to safely deliver the passengers to their destination when there are problems, such as when the weather is poor or when there are mechanical problems. You can learn a lot simply by observing and being a good assistant.In addition, a resident who makes the staff surgeon’s life easier is more likely to have an opportunity to operate on his or her patients. It is easy to feel as though you work hard on call, in the clinic, and the OR and that you deserve to get to do more surgery. Always remember that these are not your patients and that if a complication occurs, you will not have to see that patient for the rest of your career. Keeping this in mind will allow you to see the opportunity you have during your residency to learn surgery from your mentors. Pearl #4: Be availableThis sounds easy, but is often times overlooked by residents. Being available for your co-residents, faculty members, technical staff, and patients is one of the most under-rated parts of being a good resident. There is nothing more aggravating for a faculty person who needs help with or vital information about a patient than to have the resident be unavailable. Another disheartening thing is when there is a great teaching case, but the resident has left for lunch or to go home. You should not leave the clinic (for lunch or for home) until all the patients have gone.I can recall one instance from my residency, when I was on call and a trauma patient arrived with interesting eye findings. This patient arrived shortly after the end of our evening lecture and most residents headed home. The oculoplastics attending and I headed to the ER to see the patient. Along the way we encountered a second year resident that was on his way home. He asked what we were going to do and when we told him about the interesting case, he immediately came along. That act earned him more respect with the attending surgeon and showed that he was not just a “9 to 5” resident who would rather get home as soon as work was over. It also showed that he had a true interest in ophthalmology.If you are available, you will see more interesting cases, learn more ophthalmology, and have the opportunity to do more. Along these same lines, you should never turn down the chance to go to the operating room. One of the best parts of ophthalmology is getting to operate, and residency is the time to hone your skills in the presence of “battle-tested” staff members. When you are on your own in practice and come up against a tough case (especially trauma), you will reference your surgical experiences the most. The more cases you do under guidance, the more wisdom you will have when you encounter these tough scenarios. Pearl #5: Leave your ego at the doorThe biggest obstacle for many physicians is that they let their “ego” get in the way of learning, interaction with staff, and patient care. An ophthalmology residency is tough to get. Most residents are in the top quarter of their medical school class and are very accomplished academically. Patients like physicians that have confidence, but somewhere along the line this confidence can turn into arrogance. Most of the failed interactions that I have observed between faculty members, staff, and with unhappy patients results from the almighty “ego”. Sometimes it is just something as small as not being willing to apologize for keeping a patient waiting too long. Other incidents can be more serious (e.g., arguments with staff in the OR, heated discussions during rounds, or refusal to see patients on call) and can lead to serious detrimental effects on the health care team. When things seem to be getting a bit “heated”, I will often try to separate myself from the situation and ask myself if my ego is affecting my stance on something and then try to eliminate it from my view of what is going on. It is amazing how effective this can be and how it can turn a potentially bad situation into something very positive. Finally, don’t ever hesitate to admit when you are wrong. Everyone has missed a diagnosis, made a patient wait too long, or been wrong about an assumption that lead to an argument. The key thing is to learn from this and not repeat the same error. These are just a few tips for not only being a good resident, but also for getting the most out of your residency. Most of these lessons were learned as I went through my residency. I hope they can help you to avoid some of the potential pitfalls of training. Ophthalmology is a great specialty, and there are a lot of physicians that would love to have the same opportunities that we have. Don’t ever take for granted just how fortunate you are to have the opportunity to do ophthalmology as a career.
“青白联合”,以“青”为主林教授介绍道,“我在临床中做了大量的青光眼白内障联合手术。我认为,对于一个术者来讲,青白联合手术一定要把关注点放在青光眼上”。林教授进一步解释说,“因为我们知道,白内障是可逆性盲,通过良好的手术技巧是完全可以解决的。为什么做青白联合手术?很明显,主要目的是放在青光眼的控制上。因为青光眼是一个不可逆性的疾病,其对视神经的损害是不可逆的”。要提高手术的成功率,就要以青光眼为着重点。具体来讲,首先要特别注重结膜的保护。林教授解释道,“我们做了很多青白联合手术,包括单纯的抗青光眼手术,我们发现很多青光眼手术失败的原因是结膜的瘢痕化,这是传统青光眼滤过手术失败的首要原因。所以我们提出一点,青光眼手术成功的关键是结膜的保护、切口的设计,这是重中之重”。青白联合手术一般有两种操作方式:一种是单切口,就是在一个切口上完成青光眼和白内障手术;还有一种是双切口,青光眼、白内障各一个切口,共两个。林教授说:“就我个人来讲,我一直坚持用双切口,这样可以最大限度保留青光眼手术切口的完整性,减少结膜的创伤和损害,提高手术的成功率。”此外,还应注意以下几种情况:1.患者的虹膜是不健康的。有的存在虹膜后粘连,或瞳孔小,虹膜萎缩、松弛、张力不足,瞳孔不能散大。这样就对白内障超声乳化手术提出了更高的要求,一定要注重避免对眼内葡萄膜组织或者虹膜的损害,提高手术效率,尽快把皮质清除干净,减少虹膜创伤,这样做的目的是减少青白联合术后眼内非感染性炎症的发生。同时,间接减少术后结膜瘢痕的形成。这对白内障超声乳化手术的要求就更高一些,要尽可能清除干净晶状体皮质,并减少对虹膜的损害。2.这类患者往往晶状体比较大,占眼内容积大,悬韧带有不健康的状况,包括晶状体半脱位,悬韧带松弛。对于这些复杂情况,在术前一定要充分预估。超声乳化撕囊口的大小、手术的灌注流量、参数、负压,甚至瓶高设计都要做一定的调整,其设置要区别于一般单纯的超声乳化手术,以尽快完成超声乳化手术,为青光眼手术的成功提供有利的条件。3.在小眼球的条件下进行手术,有时术后会发生脉络膜渗漏、恶性青光眼等,对这种患者术前的参数设置一定要注意到需要联合一些特殊的技术上改进,比如玻璃体切除,晶状体后囊切开等情况,避免发生恶性青光眼的可能,从而提高手术的成功率。终身学习,积跬步以致千里随着科技和影像学的发展,我们对很多疾病有了新的认识,包括对疾病的预后也有了新的判断方法。林教授进一步解释道,“我认为参加继续教育尤为重要。如此次参加国际视网膜高峰论坛,我们可以近距离接触到很多在视网膜疾病领域的国际知名专家,他们给我们带来了很多新的认识。所以,我认为参加继续教育对于所有眼科医师,尤其是眼底病医师是非常有必要的。不断地学习,了解疾病研究新进展,是不论专家还是基层医师都需要的。不断学习、积累,找到病变之间的差异,提出新的观点,更加细致地观察患者的病情,这是终身需要遵循的学习原则,也是我个人的一些体会”。(来源:《国际眼科时讯》编辑部)
2018-01-18 16:03http://www.sohu.com/a/217468397_401085 编者按国际眼科时讯眼底病在整个眼科领域是最为复杂的,眼底病的诊断、治疗和鉴别诊断都很复杂,近年来,相关的研究进展也最快,如抗VEGF药物的研发无疑给医患都带来了希望,影像技术、手术技术等也都有很大的发展。在2017国际视网膜高峰论坛(IRS)上,眼底病专家们探讨了相关的热点、焦点问题。来自天津爱尔眼科医院院长、爱尔眼科医院集团眼底病学组眼外伤组组长林思勇教授在接受《国际眼科时讯》采访时也分享了其在眼底疾病诊疗策略方面的经验,及其玻璃体视网膜的微创手术理念(详情请见:细微之处见真章——林思勇教授分享玻切手术的“微创”理念)。同时,林教授还分享了其终身学习的观念与各位眼科医师们共勉。抗VEGF药物vs手术:辩证联合,贯穿全程抗VEGF药物运用到糖尿病视网膜病变(DR)的治疗具有划时代意义,极大地改善了DR患者的视功能预后,同时也极大地改变了眼底病医师对DR治疗的策略。抗VEGF药物对DR的治疗,是一个全流程的介入,不仅仅是手术中的运用,在整个DR的治疗过程中,抗VEGF都应全程介入。如对于早期DR的治疗,已有大量的研究数据表明,早期应用抗VEGF药物可以延缓甚至逆转早期的DR病程,这是一个振奋人心的改变。既往我们认为DR损伤是不可逆的,但现在国内外研究表明,对于相对早期的DR,运用抗VEGF药物治疗后,病变是可以被阻止的。因此,抗VEGF药物应及早介入DR的防治。以往认为全视网膜激光光凝(PRP)治疗DR是一个金标准,很多患者在早期、中期、术中、术后,都进行PRP治疗。但是,PRP毕竟是一个有创的治疗措施,可造成一定的对比敏感度下降、视敏度下降及视野缩小等。目前国内外研究数据表明,运用抗VEGF治疗之后,可减少或者延缓激光的使用,极大地改善了患者的视功能。而针对国内一些就诊不及时的患者,激光依然是不可替代的,但在这个阶段,抗VEGF治疗依然可以发挥它应有的作用。有些患者错过早期保守治疗、激光治疗后,不得不进行手术治疗。而在围手术期,依然需要抗VEGF药物的介入,其可减少术中出血,最大限度地保护视网膜的功能,减少并发症,提高患者预后。此外,术后依然要进行抗VEGF治疗来保护和巩固手术取得的效果。包括后期视网膜已平伏,纤维膜已去除,有些患者因为全身血糖控制不佳,或肾功能异常、血脂异常、血压异常等,均会造成新的并发症,如糖尿病性黄斑水肿(DME),它也可以发生在DR任何一个阶段中,这个阶段依然需要抗VEGF的治疗。总之,抗VEGF治疗和传统手术治疗是一个辩证的关系。抗VEGF治疗是贯穿DR治疗全过程的措施,手术治疗反过来也可以减少抗VEGF的应用。有的DR合并牵拉DME的患者,多次抗VEGF和光凝都没能控制住病情的情况下,手术可以有效减少抗VEGF的使用,也可以为患者节省更多的治疗费用。所以二者之间是辩证关系,相互影响,我们要在患者整个治疗过程中全盘考虑。
黄斑变性指随着年龄的增长,黄斑发生的退行性病变,医学上称之为年龄相关性黄斑变性,或者是老年性黄斑变性。根据最新医学调查显示,我们国家50岁以上人群黄斑变性的整体患病率达到15.5%左右,患者总数接近4000万,简单说,在50岁以上人群中,大约每6个人就有1人患有年龄相关性黄斑变性。更为严重的是,到了80岁以上患病率会达到30%左右。由此可以看出,黄斑变性的患病率随着年龄增加而逐渐升高。另外,北京和邯郸的眼病研究也有一些数据,这些数据表明由于我们国家的人口基数庞大,黄斑变性总体的患病人数绝对数量非常庞大。那么,为什么会发生黄斑变性呢?目前黄斑变性的发病机制还没有完全研究清楚,研究表明年龄越大,发生黄斑病变的危险性越大;女性湿性黄斑病变略多于男性;患有高血压、糖尿病、高胆固醇血症、心血管疾病、肥胖病等人群易并发黄斑病变;吸烟、饮酒、营养缺乏(如胡萝卜素)也可引发黄斑病变;经常暴露于蓝光和强光条件下更易发生黄斑变性。因此,对于老年人,应当尽可能避免上述的危险因素,保护黄斑功能。
中国已成为世界上老年人口最多的国家,最新人口普查数据显示,我国60岁以上老年人已占到总人口的15.5% 。视力健康是老年人健康生活的基本保障,然而,在世界卫生组织(WHO)认定的三大致盲性眼病——一白(白内障),二青(青光眼),三黄(黄斑变性)中,黄斑变性引起的不可逆视力丧失越发引起大家的关注。与白内障,青光眼相比,公众对于黄斑变性这种严重的眼病的认知非常有限,一方面没有引起足够的重视,另一方面,在患病以后不知该如何正确的就诊,进行什么样的治疗。今天我们就相关话题向大家做一简单介绍。首先,我们需要了解什么是黄斑。黄斑是正常人群眼底最为重要的结构,它位于眼底视网膜的中心区域,是人类视觉最敏锐的部位。黄斑占整个眼球视觉功能的70%-80%。黄斑主要起到精细视觉的作用,例如,区别各种颜色、读书、看报、看电视、看远方的物体,都是依靠黄斑。一旦黄斑发生病变,人的视力就会严重下降,眼前出现黑点,看东西变形,甚至视力完全丧失。正常人的黄斑功能主要有三大方面,第一:明视觉,能看到明亮的物体有赖于黄斑,第二:立体视觉,例如能分辨物体的立体感有赖于黄斑,第三:色觉,能够感知分辨各种颜色的能力有赖于黄斑。可想而知,如果黄斑发生病变,那么,我们的明视觉、立体视觉和色觉都会受到损害。了解正常黄斑功能之后,我们再来了解一下什么是黄斑变性?