外国人眼中中的外伤性白内障简介

术前自己的调查和知识科普

总结：

通过医生和医院发表的一些论文和描述，我清楚了患白内障的一点微观机理和宏观原因。也明白了自己白内障的真正原因和状态。还有的疑问就是看到一种适合青年少年这种外伤型的囊下局部的白内障的手术方式，就是白内障吸注式，具体就是不用摘除晶体。这也是最好的方法了，当然需要通过全面的眼睛结构疾病的检测和裂隙灯测试的结果才能判断，但愿我是这一种情况，那么自己不用人工晶体就可以不用花1万元的人工晶体费了。还有就是不用过几年做YAG手术来修正植入自己眼睛内部的人工晶体了。

当然如果自己正是这种情况，是否做手术还要咨询医师术后可以预测和期待的效果。

Symptom:钝挫伤（所以说发生物理伤害的第一时间不会发生白内障，而是过一段时间）

症状描述以及比对：

Cataracts are a painless clouding of theinternal lens of the eye. Because they block light from passing through thelens, cataracts make it difficult to see clearly and can even cause blindnessover time. Cataracts are progressive, meaningthey worsen with time. Most cases occur in olderpeople, but sometimes they can be seen in younger people as well.

Acataract is a clouding of the lens of the eye.

Cataracts are extremely common, and mostcataracts are a result of the aging process.

Although many cataracts are not significant enough to require treatment,surgical removal of cataracts is usually safe andeffective, resulting in improvement of vision.

Cataract surgery should be performed when the visual loss from thecataract significantly impacts the lifestyle of theindividual patient.（只要迫不得已的时候才会做这种手术，当然我会咨询一些医院的医生，结合我实际的情况，再决定是否要做这个手术，但是自己本身一直感觉这个眼睛可能影响了我的认知水平和大脑的发育程度）。

Mechanism:外伤性白内障的晶体上皮丧失其基本的三个正常功能，即细胞的分裂、移行和包括胶原及晶体蛋白在内的特殊蛋白质合成。而晶状体的上皮组织具有重要的作用，晶体上皮是晶体代谢率最高的部位，葡萄糖和氧被上皮利用。晶体上皮还含很高的 A T P 和活性酶, 晶体上皮在把碳水化合物、电解质和核酸转运人晶体时需消耗化学能 , 晶体赤道部所形成的晶体纤维的蛋白合成也需要能量。上皮的机械性损伤引起有丝分裂刺激及胸腺嘧啶脱氧核苷增加。“修复”上皮细胞延伸, 类似成纤维细胞,可在晶体囊下堆集达10 层之多。晶体囊虽含有 A T P 及糖酵解的中间体 , 但一般认为它不能单独代谢, 晶体囊需依靠与晶体上皮和纤维的接触以获得代谢物质。晶体纤维组成了晶体皮质及核的大部分 , 纤维之间的空隙很小 , 仅占晶体大小的 5 % 。在白内障形成时, 间隙增大 ; 在纤维之间水分聚集及晶体纤维破坏时 , 裂隙灯下可见到空泡和纤维断裂。外伤时损伤晶体的谷咣苷肽 ( G S H) 合成能力或增加谷咣苷肽通过膜的弥散,导致K + 离子、肌醇和氨基酸的丧失 , 晶体上皮为了保持这些化合物的浓度而增加“泵”功能。根据外伤因素的程度及持续时间 , G S H 的丧失可持续或停止 , 为了保持正常水平的G S H, 需要增加辅酶 l ( N A D P H ) 的水平 , 后者刺激戊糖代谢的途径。若上皮或纤维的结构及功能受到损害而不能排出Na+时 , 即会引致水分聚集 , 继之而来的是蛋白质合成减少 , 表现为可溶性晶体蛋白含量降低。此异常的物理化学环境常致Ga+的滞留及混浊的不溶性蛋白增加,以及二硫键 ( S-S) 的形成。此时可发现糖酵解和其它酶活性增加，如 : 破坏纤维的水解糖苷酶和晶体蛋白溶解酶活性增加。异常的晶体代谢致 A T P 丧失 , 最后导致全部晶体混独。

Mechanism abstracts：晶体上皮（ATP、活性酶）提供将碳水化合物、电解质和核酸转运到人工晶体和晶体纤维的蛋白合成所需的能量。而提供这一能量的途径可能由于机械性的损伤发生失效，确切来说，上皮延伸出来的晶体囊依靠与晶体上皮和纤维的接触以获得能量。白内障的形成致使此类接触间隙的增大而导致水分聚集和纤维断裂，上皮和纤维的损伤不能有效排出Na+离子，导致水分聚集和蛋白质合成减少，具体表现为可溶性的晶体蛋白含量减少。同时外伤时损伤晶体GSH合成能力导致K+等有效离子丧失，这就刺激机体为了保持这些化合物的浓度而增加“汞”的功能，致使出现损伤，最后的结果是这种异常的物理化学环境导致Ga+的滞留和浑浊不溶性蛋白的增加和S-S键的形成以及破坏纤维的水解核苷酸和晶体蛋白溶解酶活性的增加，致使ATP完全消失甚至不断加重这种恶性趋势。

物理宏观解释：

机械性眼外伤的程度不同,晶体混浊的类型和范围也各不相同,轻度的挫伤最常见的表现为虹膜印环;无晶体囊破裂的挫伤性白内障多是由于外力作用于眼球后,力量通过房水间接传至晶体, 或由玻璃体的反作用致晶体震荡伤, 最终使晶体囊和上皮代谢紊乱, 渗透压增加,纤维之间水分聚集及纤维破坏致晶体混浊。穿通伤及挫伤致囊膜撕裂时,房水大量进入晶体导致晶体纤维膨胀、混浊, 皮质转变成稀松的絮状物质。

手术后恢复训练：术后及时进行弱视训练对于重建双眼单视是非常关键之步骤

手术方法：白内障囊内摘除术、白内障囊外摘除术、超声乳化白内障吸除术、白内障囊外摘除与后房型人工晶体植入手、白内障小切口手术等

其中我可能会被施行的手术形式：白内障吸除术（aspiration of cataract）该种手术方式是指切开晶状体前囊，通过微小切口，注入注吸针头抽吸出混浊的软核和皮质，手术过程中不需要摘除晶状体，手术操作简单，愈合快速，但适用范围较小，仅适用于如外伤性、并发性白内障等成年人的软性白内障和无硬核的先天性白内障。

咨询的问题：

·有没有必要植入晶状体（人工晶体AL可能会出现若干年加厚和不适应，对于青年来说我感觉不是很好），既然能够直接吸除软核和皮质，是否能够修复已经发生的纤维和上皮的损伤，回复眼部的机能？还是无法恢复这种已经出现局部破坏的现象，需要摘除晶状体植入人工的晶状体（这里人工的晶体虽然软质的昂贵和普遍适用，但是也有缺点，就是容易脱落和发生畸变，硬质的一次固定，但是术后的视力似乎不佳，也就大概模糊能看见的样子）。

当然，术后都会出现散光。（散光是指平行光线通过眼球折射后所形成的像并非一个焦点而是在空间不同位置的两条焦线和最小弥散圆的一种屈光状态）。

具体的描述：recognition

（眼睛的工作流程）The lens is a portion of the eye that is normally clear. It focusesrays of light entering the eye onto the retina, the light-sensitive tissue atthe back of the eye. In order to get a clear image onto the retina, theportions of the eye in front of the retina, including the lens, must be clear and transparent.The light striking the retina initiates a chemical reaction within the retina.The chemical reaction, in turn, initiates an electrical response which iscarried to the brain through the optic nerve. The brain then interprets whatthe eye sees.

In a normal eye, light passes through thetransparent lens to the retina. The lens must be clear for the retina toreceive a sharp image. If the lens is cloudy froma cataract, the image striking the retina will be blurry or distorted and the vision will be blurry.The extent of the visual disturbance is dependent upon the degree of cloudinessof the lens.（光线对视网神经的刺激不够或者是分散）

Most cataracts are related to aging. Cataracts are very common in older people. （老年人几乎一半会得白内障，也是我们说的人老了，眼睛花了等）By age 80, more than half of all Americans either have some degreeof cataract or have already undergone cataract surgery in one or both eyes. Byage 95, this percentage increases to almost 100%. A cataract can occur ineither or both eyes. Individuals with a cataract in one eye usually go on todevelop a cataract in the other eye as well.（一个眼睛有白内障，往往会刺激另一只眼睛也患有白内障，这是人体复杂得反应与机能得类比吧） A cataract is not contagious and cannot spread from one eye to theother or from person to person. Cataracts do not cause the eye to tearabnormally. They are neither painful nor make the eye itchy or red.

Although vision can be restored in mostpeople with cataracts, age-related cataracts are still the most common cause ofblindness in the world, primarily because many third-worldnations lack appropriate and available surgical services.

As life span increases in the developedworld due to modern technology and new methods of treatment of acute andchronic disease, the incidence of age-related cataracts will continue to increase.

What are the different types of cataracts?

Cataracts can be classified by anatomical location within the lens, degree ofclouding of the lens, or by the cause of the cataract.

The lens of the human eye is shaped andsized similar to an M&M candy. It has a front (anterior)part and a back (posterior) part. The centralportion of the lens is called the lens nucleus,and the outer portion is called the lens capsule.Between the inner nucleus and the outer capsule is a portion of the lens calledthe cortex. Clouding of the lens can occur onlyin the nucleus, in which case the term "nuclearcataract（核部）" or "nuclear sclerosis" is used. If the cloudingoccurs in the lens cortex only, the cataract istermed a "cortical cataract（皮质部）." If the loss of clarity of the lens is primarily in oradjacent to the capsule, the term "subcapsularcataract（囊下）" is used. The location of theclouding can also be defined as being anterior or posterior, central, orperipheral. Often the clouding of the lens may affect multiple portions of thelens. The most common type of cataract that is related to age is sometimestermed a "senile cataract." This type of cataract primarily involvesthe nucleus of the lens. Cataracts that develop in theposterior subcapsular area (in the rear region of the lens capsule) are morecommon in younger age groups.（障碍物出现得地方有晶体核lens nucleus（老年人出现），晶体核前部anterior，晶体核后部posterior，晶体核前部的韧带相接处adjacent to the capsule，我的障碍物质就在皮质部前特有的区域-囊下吧）

Any degree of loss of the normaltransparency of the lens is called a cataract. The cloudier the lens, the moreadvanced the degree of cataract. A cataract may be mild, moderate, or severe.It may be early or advanced. If the lens is totally opaque it is termed a"mature" cataract. Any cataract that is not opaque is thereforetermed an "immature" cataract（我的肯定是这种不成熟，没有全覆盖的）.Most mature cataracts are white in color.

What are risk factors for cataracts?

Advanced age is a significant risk factorfor the development of cataracts. A family history for early development ofcataracts, the presence of diabetes, tobacco use, and prolonged exposure tosunlight are also risk factors, as is trauma to the eye.

What are causes of cataracts?

The lens is made of mostly water and protein. The protein is arranged in aspecific way that keeps the lens clear and allows light to pass through it tofocus a clear image onto the retinal surface. As we age, some of the proteinmay clump together and start to cloud a small area of the lens. This is ourunderstanding of the cause of an age-related cataract. Over time, the cataractmay become denser or cloud more area of the lens, making it more difficult tosee through. A cataract is not a growth or tumor. （有序的蛋白质排列致使光线通过，而年龄的增长，这种无序和杂乱的排列就会增加而致使盲（老年人的情况））

There are many other causes of cataractsbeyond advancing age. Whatever the cause, all cataracts are a result of similarchanges to the protein of the lens, similarly resulting in visual blurring orvisual loss.

Blunt or penetrating injury （钝的物体刺伤）tothe eye may result in a cataract, either immediatelyafter the injury or some weeks to years afterward. （不是立马显示出来，而是伤后或是几周）A cataract following an injury may appear and then not increase indensity (be stationary) or be progressive.（当然这种伤害不会继续恶化） Eye surgery forother conditions can also cause cataracts. Excessive exposure to ionizingradiation (X-ray), infrared radiation (as in glass blowers), or ultravioletradiation may also cause cataracts.

Diabetes is associated with the developmentof cataracts. Inflammatory disease of the eye, such as iritis or uveitis, maycause or accelerate the development of cataract in the involved eye.

There are many genetic illnesses that are associated withthe development of cataracts. These include myotonic dystrophy, galactosemia,homocystinuria, Wilson's disease and Down syndrome, plus many others.Congenital infections with herpes simplex, rubella, toxoplasmosis, syphilis,and cytomegalic inclusion disease may also result in cataracts.

There are many medications which, whentaken over a long period of time, can cause secondary cataracts. The mostcommon of these are oral corticosteroids, such as prednisone, which currentlyare used for a wide variety of medical conditions.

The term "congenital cataract" isused when a baby is born with any clouding of the lens. This may be present inone or both eyes, be stationary or be progressive. Causes include geneticdisorders or infectious or non-infectious intrauterine developmental disorders,both often associated with other physical abnormalities of the baby.

Atopic dermatitis, other diseases of theskin and mucous membranes, hypothyroidism, and hyperparathyroidism areassociated with the early development of cataracts.

Patients who develop cataracts in both eyesat an early age often have family members who have also developed cataractsprematurely, implying a genetic cause, even in the absence of a recognizedunderlying disease.

What are the symptoms of cataracts?

You may not notice any symptoms with earlycataracts. As a cataract becomes more advanced, decrease in clarity of vision,not fully correctable with glasses, is noticed. There is a loss of contrastsensitivity, so that shadows and color vision are less vivid. Disturbing glaremay be noted as light is into the eye scattered by the cataract. Haloes may beobserved around lights. Night vision will be diminished. In certain types ofcataracts, double vision may be noted in the affected eye. Some patients notethat they require frequent changes in their eyeglass or contact lensprescriptions and may be aware that their near vision is improving as theirdistance vision declines.

A cataract does notroutinely cause discomfort or pain in the eye or alter the external appearanceof the eye（无痛不伤害外观）

What are the signs of cataracts?

Family members of a person affected bycataracts in both eyes may notice that he or she appears not to be seeing aswell as previously. The eye will appear normal to the untrained observer,unless the cataract is mature and white. In that situation, the pupil of theeye, which normally appears black, will look grey or white to the observer.

The examining physician will find diminished visual acuity in the affected eye or eyes. Thisvisual loss is not fully corrected by a change in the glasses. The lens of theeye can be easily examined by an ophthalmologist and the changes in the lenscharacteristic of cataract can actually be seen using a slit lamp, which is an illuminating andmagnifying device used to painlessly examine the structures within the front ofthe eye, including the lens.（对于我是否得了哪一种白内障，我还是做一下这个裂隙灯显微镜测验来检测我眼部前面的结构和晶体）有必要

What types of specialists treat cataracts?

Ophthalmologists are medical doctors whohave specialized in the diagnosis and medical and surgical treatment of eye disease.Ophthalmologists both diagnose cataracts and surgically remove cataracts whenindicated.

How do health-care professionals diagnose cataracts?

Cataracts are relatively simple to diagnoseby an ophthalmologist or an optometrist during a routine eye examination. It isimportant, when making the diagnosis of cataract, toalso examine the entire eye for evidence of any other eye disease whichmay be compromising the vision. In addition to taking a medical and ocularhistory and visual acuity test, the ophthalmologist will check eye movementsand pupillary responses, measure the pressure inside the eyes and examine theboth front and back of the eyes after the pupils have been dilated with drops.（虽然白内障很容易判断，但是要确证，还需要对整个眼睛的检测和眼睛是否有其他疾病，另外，眼部的医疗历史和眼部敏锐程度的测试，检测眼部的活动和反应水平，测量眼内部的眼压和测量眼睛的前部以及后部）（到海淀医院需要做的事情）

What is the treatment for cataracts?

People with early cataract will find thatchanging their glasses, using sunglasses to decrease glare and having betterlighting to read can significantly alleviate their symptoms. Magnifying lensesfor close work and reading fine print may also be helpful.

Many cataracts are not bothersome, causingfew symptoms. In that situation, no surgical treatment is necessary.(如果影响不大，没有必要手术)However, the only truetreatment for cataract is surgical removal of the cloudy lens. Surgery is suggested if the patient loses the ability toperform necessary activities of everyday life, such as driving, reading, orlooking at computer or video screens, even with glasses, and there is the expectationthat vision will improve as a result of the surgery.（手术只有在一个人带了眼睛，或是无法驾驶，看东西，看电脑的情况下才会建议）

Patients' responses to the presence of acataract vary. A cataract in only one eyemay be disturbing to a particular patient and may not cause significantsymptoms in another patient.

Cataracts usually donot harm your eye, so you can have surgery when it isconvenient for you and when the cataract interferes with your daily activities.Once you understand the benefits and risks of surgery,you can make an informed decisionabout whether cataract surgery is right for you. In most cases, delaying cataract surgery will not cause long-term damageto your eye or make the surgery more difficult.（操作是对的，延期并不会造成手术难度的增加和眼部的伤害的加剧）

If the eye has other diseases that havecaused visual loss such as glaucoma, macular degeneration, diabeticretinopathy, or optic nerve damage from glaucoma or other disease, cataractsurgery may not improve the vision.

Occasionally, your doctor may recommendremoval of a cataract if it prevents the diagnosis or treatment of another eyeproblem, such as macular degeneration or diabetic retinopathy.

If both eyes have cataracts and surgery isagreed upon, the surgery on the second eye is generally planned at least a weekafter the first eye. There is usually no harm in waiting a much longer periodof time between the two eye operations.

Because the lens of the eye is necessary toaccurately focus light onto the retinal surface and removal of the cataractinvolves removal of the lens, modern cataract surgery combines removal of thelens and placement of a new artificial lens into the eye. Measurements for thesize, shape, and power of this lens will be taken prior to the surgery so thatthe specific lens can be available for implantation at the time of surgery.

More than 3 million cataract surgeries areperformed annually in the United States. Cataract surgery is extremely safe and effective, improving vision in thevast majority of patients.（是相对与完全看不见有所增加，可惜永远无法真的复明，老年人苟延残喘之计）

Whatare risks of the different types of cataract surgery? How long is the recoveryafter cataract surgery?

Cataract surgery is usually performed as anoutpatient procedure under local anesthesia. Some sedation is ordinarily givenintravenously just before the beginning of the surgery, which usually takesunder a half-hour.（手术大概一小时）

Most cataract surgery today is done througha small incision by phaco-emulsification or by other means through a slightlylarger incision. In more than 95% of cases, a new lens, known as a lens implantor intraocular lens is inserted at the same time as the cataract removal. Youwill not feel the new lens within the eye. Mostpatients need to limit their activities for only a few days and recovery timeis brief.（术后仅需注意几天就无大碍了）

Although modern techniques have madecataract surgery quite safe, complications can occur with any surgicalprocedure, including cataract extraction. These include hemorrhage, infection,loss of a portion of the cataract into the eye, displacement of the intraocularlens, glaucoma, and retinal detachment. Fortunately, all these complicationsare rare and usually can be managed. Blindness is a rare complication ofcataract surgery.

Modern cataract surgery involves leaving aportion of the lens capsule within the eye to support the intraocular lens. This capsule may become cloudy at a later time,necessitating opening of the capsule through the use of a laser. Thisoutpatient procedure is called a YAG laser capsulotomy. It is painless andrarely results in increased eye pressure or other eye problems.（通常几年之后需要简单的有激光破开晶体修正一下）

What are complications of cataracts?

Occasionally, a very dense cataract oflong-standing duration may enlarge in size and interfere with fluid drainagewithin the eye. In addition, a far advanced cataract may leak protein into theeye, causing inflammation of the eye. Your doctor will advise you of thesepossibilities and may recommend surgery to avoid these complications even ifthe decrease in vision is not bothering you.

The presence of a cataract may makeevaluation of diseases of the retina more difficult, since the physician mustlook through the cataract to examine the retina.（往往白内障导致难以检测后面的视网膜是否正常，所以在手术前检测这个视网膜）。

Is it possible to prevent cataracts?

Everyone, if they live long enough, willdevelop cataracts. There is no scientifically proven method that prevents theinevitable. Progression of cataracts can be slowed by avoiding large amounts ofultraviolet light, not smoking, avoiding trauma to either eye, and following ahealthy diet. Wearing UV-protection sunglasses when exposed to sunlight can behelpful.

What is the prognosis of cataracts?

The rate ofprogression of cataracts is usually predictable and surgery is successful inrestoring vision in a large majority of cases. If otherdiseases are present within the eye, the degree of visual improvement will belimited by the other disease process. Ophthalmologists can usually determinethis in advance.（术后绝大多数人恢复光明，但是这个光明即使是可预测和课评估的，是恢复到原来的样子吗？这也是决定我是否做手术的关键因素）需要做全面的检测之后，咨询医生之后，才能做出决定）。

手术的一些流程描述和注意事项：

A week or two before your procedure, your doctor will do some tests to measurethe size and shape of your eye. This way, she can choose the best artificiallens for you.She'll probably tell you not to eat or drink anything for 12 hours before the surgery.You won't need to stay overnight at the hospital, but you'll needsomeone to drive you home.

After Surgery. For a fewdays after surgery, your eye may itch or feel sore.During this time, you may also have some tearing and find it hard to see wellin bright light.

Your doctor will give you eyedrops toprevent infection. You'll need to take it easy for a few days. Driving will beoff-limits, and you shouldn't bend over, pick up heavythings, or put any pressure on your eye.

For the first week, your doctor will likely suggest you wearan eye shield while you sleep. This protects the site of your surgery soyour eye can heal. If you're in pain or you feel your eye isn't healing like itshould, tell your doctor right away.

After 8 weeks, your eye should be fully healed. About 90% of people see betterafter cataract surgery. But don't expect your vision to be perfect. You maystill need to wear glasses or contacts.

人工晶状体的后果。Month and year to notice that you lens will thick and need you anotherprocess which will use laser to open up the lens and fix it.

A surgeon uses a laser to open up thethickening around the lens capsule and let more light get through yourartificial lens. That will clear up your cloudy vision.

2017年12月25日星期一

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