ghost cell glaucoma
Introduction
Introduction to blood shadow cell glaucoma In 1976, Campbell et al first reported that in the case of vitreous hemorrhage and anterior chamber hemorrhage due to eyeball contusion, degenerated red blood cells are called blood-stained cells, and occlusion of the trabecular meshwork leads to an increase in intraocular pressure, which is named as ghostcell glaucoma. . basic knowledge Sickness ratio: 0.0001% Susceptible people: no specific population Mode of infection: non-infectious Complications: ocular hypertension
Cause
Cause of blood cell glaucoma
(1) Causes of the disease
The vitreous and anterior chamber blood caused by various reasons is the root cause.
(two) pathogenesis
1. The formation of blood-stained cells The blood of the glass or the blood that enters the vitreous is not easily absorbed. After a few days, its morphology, color and rheology change, and the red bifocal surface and soft characteristics of normal red blood cells disappear. The yellow-brown hollow or nearly spherical outer shell, the membrane becomes thinner, the brittleness increases, and many micropores are produced. The hemoglobin escapes from the membrane through the micropores, and evolves into methemoglobin by oxidation, which is then denatured into many globin particles. , deposited on the surface of the cell membrane, called Heinz body, some small bodies combined to form a different size (0.3 ~ 2.0m), how many different (1 ~ 20) of the polymer, almost no hemoglobin, only in the cell body There are a few irregular agglomerates on the edge, and the Heinz body is attached to the membrane. It is faintly visible. Translucent hollow denatured red blood cells, called blood shadow cells, can also occur elsewhere, but are more easily observed in the vitreous. The change can be completed within 1-3 weeks. Once the blood cells are formed, it will not undergo further degeneration. In this form, it can stay in the vitreous for several months, it does not adsorb The fibers of the glass are suspended in the vitreous body and finally gather in the vicinity of the anterior vitreous membrane. They enter the anterior chamber through the slits in the anterior vitreous membrane. Thousands of blood-stained cells can accumulate in the anterior chamber. On the other hand, In the process of transformation into blood cells, most of the cells are dissolved, and the fragments and denatured hemoglobin can be removed by phagocytosis from macrophages at the ciliary body and optic disc, and the vitreous cavity gradually clears. It does not play a major role in the pathogenesis of glaucoma.
2. Mechanism of glaucoma-induced glaucoma Normal red blood cells are biconcave-shaped, 8 m in diameter, soft in cell membrane, strong in plasticity, and capable of large deformation. It can smoothly pass the filter of 5 m diameter and the narrowest microcirculation of 3 m diameter. In the anterior chamber, the Schlemm tube can be accessed through the trabecular meshwork, but after the normal red blood cells become blood shadow cells, the cell body is swollen, which is a hollow yellow-brown spherical or nearly spherical body with a diameter of 4-8 m, translucent, and membrane. Poor plasticity, increased brittleness, can not pass the 5m filter, it is difficult to discharge the road through the aqueous water. Experiments have shown that when the fresh red blood cells are fixed with acetaldehyde diacetate, they lose the above ability, if at 20mmHg (2.66kPa) Under constant pressure, 50% of the blood cell suspension was used as the anterior chamber perfusion of the human eye. After 30 minutes, the C value decreased by 73%, and its resistance to the aqueous drainage channel was about 3 times that of normal red blood cells. It is proved that the ratio of fresh red blood cells to blood cells in the original anterior chamber is 50:50, and it is changed to 96:4 in the upper scleral vein. This also indicates that it is difficult for blood cells to pass through the road, using light and electron microscopy. room Tissue, they found ghost cells or only through the outer 1/3 of the trabecular meshwork, Quigley other apes injected anterior 1980 ghost cells, causing glaucoma.
The above experiments have strongly demonstrated that the occlusion of the trabecular meshwork by the blood-stained cells is the most important cause of open-angle glaucoma. In addition, the integrity of the anterior vitreous membrane is also closely related to the formation of glaucoma. Fresh red blood cells or blood shadow cells can not pass through the intact vitreous membrane. In clinical observation, such as vitreous hemorrhage and anterior vitreous membrane, there is no fresh bleeding or bleeding in the anterior chamber. If the anterior vitreous membrane is ruptured or a rare spontaneous rupture due to trauma or surgery, the blood-stained cells can enter the anterior chamber from the rupture, block the trabecular meshwork and develop glaucoma.
The anterior chamber blood is also one of the sites that form blood cells, but glaucoma does not necessarily occur. It must be caused by an increase in intraocular pressure when the number of cells is sufficient to block the drainage of the trabecular meshwork. In fact, the anterior chamber The red blood cells, which are generally absorbed for a short period of time, are absorbed, and the chances of becoming blood cells are also less. The blood absorption in the vitreous is slower, and the blood cells are prone to occur, but only when the anterior vitreous membrane is broken. Then move to the front room.
Prevention
Blood shadow cell glaucoma prevention
Pay attention to self-protection and prevent various predisposing factors.
Complication
Hemocytic glaucoma complications Complications, high ocular hypertension
Changes in the fundus and optic nerve caused by high intraocular pressure, corneal edema and other trauma to the eye.
Symptom
Hemophagocytic glaucoma symptoms Common symptoms Increased intraocular pressure, high intraocular pressure, eye pain, no lens
Clinical type
Hemophilic glaucoma patients always have a history of vitreous hemorrhage, which can be caused by trauma, surgery or primary retinal diseases such as diabetes. Most patients develop vitrectomy, cataract extraction or trauma.
(1) After the vitrectomy, the blood-stained cell glaucoma: the vitreous glaucoma can occur after the vitreous occlusion of the vitreous occlusion, and the vitreous cells can be inserted into the anterior chamber due to the vitreous membrane before the surgical injury. Glaucoma occurs several days or weeks after surgery. The high intraocular pressure caused by this condition can last for several weeks. If the vitreous surgery only removes the middle zone of bleeding, the surrounding hemorrhagic substances, including the blood cells, may be sourced for a long time. The blood cells are constantly moved to the front room. If most of the bleeding is removed, the incidence is reduced, and the incidence of vitreous and simultaneous lens cleavage, or aphakia is increased.
(2) ocular cataract glaucoma after cataract extraction: it is a rare and easily overlooked disease, which can occur in intracapsular enucleation, extracapsular cataract extraction, iris-fixed anterior chamber intraocular lens implantation, and capsule There are 3 cases of broken holes. First, a few days after the operation, there is a lot of bleeding in the anterior chamber. The anterior capsule is broken into the vitreous. Usually, the anterior chamber blood is more easily absorbed than the vitreous, and the anterior chamber is caused by hemorrhage. High intraocular pressure often decreases within 1 to 2 weeks, but if the intraocular pressure rises again in 2 to 6 weeks, and the appearance of blood cells remains in the anterior chamber, the reason for the increase in intraocular pressure may be the blood in the vitreous. The cells re-enter the anterior chamber to block the trabecular meshwork, and the other is the preoperative patient's original vitreous hemorrhage. The blood-stained cells present in the vitreous enter the anterior chamber through the posterior capsule and the rupture of the anterior vitreous, at this time a few days after the operation. There will be a significant increase in intraocular pressure. Another condition can occur in the late stage of cataract surgery. Due to retinal diseases, vitreous hemorrhage, degenerated red blood cells enter the anterior chamber, and sometimes coexist with fresh bleeding.
(3) Post-traumatic blood-stained glaucoma: no matter the contusion or perforation injury can cause anterior chamber hemorrhage and vitreous hemorrhage. When there is a hole in the anterior vitreous membrane, the anterior chamber is formed. The bleeding can cause short-term intraocular pressure to increase, and the intraocular pressure decreases with the absorption of hemorrhage. The bleeding into the vitreous can gradually become blood cells, and then enter the anterior chamber, causing the intraocular pressure to rise again, and more often after the injury. ~ 3 weeks, if the anterior chamber blood becomes a blood clot, the oxygenation is reduced, it is easy to become a blood shadow cell, causing a sustained increase in intraocular pressure, and blood cells can be found in the blood clot by taking out the blood clot.
(4) Non-invasive and surgical blood-stained glaucoma: relatively rare, diabetic retinopathy, vitreous hemorrhage can cause glaucoma glaucoma, glaucoma can occur several years after glass hemorrhage, these cases are due to the pre-vitreous membrane Defects cause spontaneous rupture and vitreous liquefaction, which can also occur in severe uveitis, myopia, vitreoretinal degeneration, the elderly, or simple chronic vitreous hemorrhage, blood shadow caused by non-traumatic vitreous hemorrhage Cellular glaucoma should be given attention.
2. Clinical features
(1) Medical history: There are generally vestibular hemorrhage and/or vitreous hemorrhage caused by trauma, surgery, or retinal diseases, which occur mostly in the days after the glass volume of blood for several days to several weeks, accompanied by prophase When blood is present, it is often characterized by open-angle glaucoma after effusion of the anterior chamber.
(2) Intraocular pressure: When there is a small amount of blood shadow cells in the anterior chamber, there is no effect on intraocular pressure. A large number of blood shadow cells enter the anterior chamber and cause a sharp increase in intraocular pressure, reaching 60-70 mmHg (8.0-9.0 kPa). Intense eye pain, corneal edema, high intraocular pressure can last for weeks or months, and its duration depends on the amount of blood cells in the vitreous and the ability of the trabecular meshwork to clear the blood cells. Continuous high intraocular pressure can cause Serious visual impairment, even blindness.
(3) anterior chamber: blood shadow cell glaucoma, regardless of the type, the common feature is that the blood shadow cell floats in the anterior chamber, the slit lamp examination shows that there are numerous yellow-brown small particles suspended in the anterior chamber, and the cycle is very slow. It is often mistaken for white blood cells. When there are a large number of blood-shadow cells in the current room, a layer is formed below the anterior chamber. The top is a yellow-brown blood-shadow cell, and the red blood cells below are easily misdiagnosed as grapes. Membrane inflammation or anterior chamber empyema, the difference between inflammation and inflammation is that although there are a large number of cells in the anterior chamber, there is no KP after the cornea, and a layer of fine yellowish particles can be attached, unless high intraocular pressure and no inflammation in the eyes. The conjunctiva is not congested.
(4) Vitreous: vitreous opacity, the degree is not equal, in the front vitreous, there are many fine yellow-brown particles suspended, in the aphakic eye, occasionally the blood-shadow cells swim forward and pass the rupture of the anterior vitreous membrane Enter the front room.
(5) Fundus: Because of the volume of blood in the glass, it is usually difficult to see. If the fundus is visible, there is no obvious change in the early stage. If the treatment is not timely or the long-term high intraocular pressure, it may cause glaucomatous optic disc depression and even glaucomatous optic atrophy.
(6) iris keratoscopy: showing a normal wide angle, it can also be a yellow-brown cell covering the trabecular meshwork, or filled with the corner below, the appearance of the anterior chamber empyema, but different from the real pus, There are different colors and levels, and they do not move with the change of body position.
At any time within 3 to 4 weeks after the blood volume of the glass, the intraocular pressure rises to 30-70 mmHg, and a large number of very small cells appear in the aqueous humor of the anterior chamber, but there is no KP in the posterior wall of the corneal endothelium, and suspicious blood cells should be considered. Sexual glaucoma.
There are fresh or old vitreous hemorrhage or severe anterior chamber blood in the medical history, which may be caused by ocular trauma, internal eye surgery, such as early or preoperative cataract extraction, vitreous hemorrhage, or retinal blood vessels. The vitreous hemorrhagic disease and the history of pre-vitrified membrane damage in sexually transmitted diseases are also important. In addition, elevated intraocular pressure and slit lamp examination are also important.
Examine
Examination of blood-stained cell glaucoma
1. The examination of cytology of living specimens is the most important diagnostic basis. The fresh aqueous humor is taken immediately under the phase contrast microscope. Do not use dry specimens, and do not need to stain, centrifuge or filter the specimens to find a large number of The characteristic Heinz bodies are in red blood cells.
2. Laboratory tests for certain primary diseases such as diabetes associated with bleeding may be performed.
3. gonioscopic examination: the iris cornea angle is normal, but if there are a large number of blood cells in the anterior chamber, it may be seen that the trabecular meshwork becomes shallow ochre, and the anterior chamber of the severely ill cells should be exuded with inflammatory cells. The difference between things or empyema.
Diagnosis
Diagnosis of blood cell glaucoma
Diagnostic criteria
Typical medical history and physical signs are not difficult to diagnose. In the absence of typical clinical features, it is easy to miss diagnosis or misdiagnosis. Anyone who meets the following conditions may consider this disease:
1 has fresh or old vitreous hemorrhage;
2 sudden increase in intraocular pressure from several days to several weeks after hemorrhage; 3 small yellow-brown particles floating in the 3 aqueous humor or "anterior chamber empyema";
4 corners are open, there are yellow-brown objects on the trabeculae; 5 no KP, no neovascularization in the iris.
The exact diagnosis depends on the cytological examination of the aqueous humor or vitreous extract, which can be diagnosed once the blood cells are found.
Differential diagnosis
1. Hemolytic glaucoma The red blood cell debris formed during the hemolysis process and the glaucoma caused by macrophage occlusion of the trabecular meshwork, the clinical symptoms and signs are similar to the blood-stained cell glaucoma, many found by the aqueous examination. Macrophages and broken red blood cells are the main markers.
2. Blood iron glaucoma A rare type of glaucoma caused by trabecular iron deposition and injury, chronic clinical manifestations, no ocular cells in the anterior chamber, often occur many years after injury, and blood-stained glaucoma often occurs in the vitreous Or weeks to months after the anterior chamber is hemorrhagic.
3. Neovascular glaucoma is often accompanied by a vitreous hemorrhage and high intraocular pressure, but there is no blood-shadow cells in the anterior chamber, and iris neovascularization is different from blood-stained cell glaucoma.
4. The retrograde glaucoma with vitreous hemorrhage caused by eyeball damage can also be confused with this disease, but this kind of glaucoma has a late onset time, which occurs many months after the contusion and many years. Careful corneroscopy It is not difficult to distinguish after the slit lamp inspection. There is a corner of the anterior chamber, the ciliary body is widened and the anterior chamber is deep, and there is no blood-staining cells in the aqueous humor.
5. Uveitis secondary glaucoma has KP, aqueous humor, iris adhesion and other characteristics, and different from blood-stained cell glaucoma, pay attention to distinguish the yellow-brown material in the anterior chamber, not as white blood cells, deposition of blood cells Do not be regarded as true anterior chamber empyema, no response to corticosteroids and antibiotics is characteristic of blood cells.
