文/梅 穎

弱視屈光矯正后是否還需要做視覺(jué)訓(xùn)練?

文/梅 穎

最近在做RGP屈光不正性弱視的治療效果方面的講座時(shí)，有不少同學(xué)詢問(wèn)對(duì)弱視患者做屈光矯正后，還需要做弱視訓(xùn)練嗎？弱視訓(xùn)練有多少作用？也有家長(zhǎng)表示弱視兒童做訓(xùn)練難堅(jiān)持，能否不做？

正好前不久看到AAO（American academy of ophthalmology，美國(guó)眼科學(xué)會(huì)）的弱視臨床指南（PPP，preferred practice pattern）有相關(guān)的介紹。感興趣的同學(xué)可以在AAO的網(wǎng)站上下載全文。

圖1 美國(guó)眼科學(xué)會(huì)的弱視臨床指南

圖2 2012年的弱視臨床指南PPP

1 弱視治療的重點(diǎn)

先回顧一下這個(gè)PPP，PDF格式下全文共44頁(yè)，內(nèi)容非常多，懶人就直接看重點(diǎn)吧。

圖3

為方便學(xué)習(xí)，我把上述重點(diǎn)（highlight）簡(jiǎn)單翻譯、解讀一下：

Treatment of refractive error alone can improvevisual acuity in children who have untreated anisometropic and strabismic amblyopia. Visual acuity of children who have bilateral refractive amblyopia also can substantially improve with refractive correction alone. (strong recommendation, good evidence)

僅僅矯正屈光不正就可以改善未經(jīng)治療屈光參差和斜視性弱視兒童的視力。雙眼屈光不正性弱視兒童的視力也可以通過(guò)屈光矯正顯著改善。（強(qiáng)推薦，高質(zhì)量的證據(jù)）——解讀：屈光矯正非常重要，僅僅靠屈光矯正就治了一半的弱視。

Most children who have moderate amblyopia respond to initial treatment consisting of at least 2 hours of daily patching or weekend atropine. (strong recommendation, good evidence for treatment of amblyopia)[discretionary recommendation, good evidence for dosage (amount of time) of treatment]

Patching may be effective in older children and teenagers particularly if they have not previously been treated. (good evidence)

大多數(shù)中度弱視的兒童對(duì)由每天至少2小時(shí)的遮蓋或周末滴用阿托品組成的起始治療有反應(yīng)[對(duì)于弱視治療來(lái)說(shuō)是強(qiáng)烈的建議，高質(zhì)量的證據(jù)；對(duì)于治療的劑量（時(shí)間量）來(lái)說(shuō)是自行決定的建議，高質(zhì)量的證據(jù)]——解讀：遮蓋和健眼阿托品壓抑對(duì)中度弱視兒童初期治療很好。

遮蓋可能對(duì)大齡兒童和青少年也有效，特別是如果他們之前沒(méi)有接受過(guò)弱視治療。（高質(zhì)量的證據(jù)）——解讀：對(duì)大齡兒童和青少年也不要放棄弱視治療，遮蓋一下試試。

Children who have amblyopia require continued monitoring, because about one-fourth of children successfully treated for amblyopia experience a recurrence within the first year after treatment has been discontinued. (strong recommendation, good evidence)

患有弱視的兒童需要繼續(xù)監(jiān)測(cè)，因?yàn)榇蠹s四分之一成功治療弱視的兒童在治療中止后的第一年內(nèi)會(huì)出現(xiàn)復(fù)發(fā)。（強(qiáng)推薦，高質(zhì)量的證據(jù)）——解讀：弱視會(huì)復(fù)發(fā)，即使視力提高了也需要持續(xù)觀察復(fù)診。

Successful amblyopia treatment may have its greatest impact in later life, when fellow eyes can be injured or affected by diseases of the macula or optic nerve. (insufficient evidence)

當(dāng)健眼可能受到黃斑或視神經(jīng)的疾病的傷害或影響時(shí)，成功的弱視治療可能對(duì)患者以后的生活產(chǎn)生很大的影響。（低質(zhì)量的證據(jù)）——解讀：如果從小不治療弱視，以后有一天健眼（好眼睛）出問(wèn)題就很麻煩了。

2 弱視治療的具體策略

再看看具體的弱視治療：

圖4

Success rates of amblyopia treatment decline with increasing age. However, an attempt at treatment should be offered to children regardless of age, including those in later childhood. The prognosis for attaining normal vision in an amblyopic eye depends on many factors, including the presumed onset of amblyogenic stimulus; the cause,severity, and duration of amblyopia; the history of previous treatment; adherence to treatment recommendations; and concomitant conditions.

In managing amblyopia, the ophthalmologist strives to improve visual acuity by using one or more of the following strategies. The first is to address causes of visual deprivation. The second is to correct visually significant refractive errors. The third is to promote use of the amblyopic eye by penalizing the fellow eye. While not always achievable, the goal is equal visual acuity between the two eyes. The recommended treatment should be based on the child's age, visual acuity, and adherence with previous treatment as well as the child's physical, social, and psychological status.

上述弱視治療策略的重點(diǎn)翻譯、說(shuō)明一下：

弱視治療的成功率隨著患者年齡增加而下降。無(wú)論患者的年齡大小，包括大齡兒童，都應(yīng)當(dāng)嘗試治療。弱視眼的預(yù)后取決于許多因素，包括造成弱視原因的起始時(shí)間，弱視的原因、嚴(yán)重程度和持續(xù)時(shí)間，以前治療史，對(duì)治療建議的依從性以及并發(fā)情況等。眼科醫(yī)師可以通過(guò)下述的一種或多種策略來(lái)努力提高弱視眼的視力。

第一種策略是消除形覺(jué)剝奪的原因。——解讀：比如做手術(shù)處理先天性白內(nèi)障、處理上瞼下垂等。

第二種是矯正在視覺(jué)上有意義的屈光不正。——解讀：比如矯正高度遠(yuǎn)視、矯正屈光參差、矯正高度散光等。在光學(xué)矯正工具（框架眼鏡、接觸鏡）中，RGP的光學(xué)矯正效果最好，成像質(zhì)量最佳，弱視治療效果也最好。

第三種是通過(guò)遮蓋對(duì)側(cè)眼來(lái)促使弱視眼的使用。——解讀：遮蓋健眼，逼迫弱視眼的視覺(jué)發(fā)育。

這三種方法是弱視治療的基本原則。

·Optical correction52,126-128

·Patching59,60,129,130

·Pharmacological penalization52,59,60,129,131-136

·Optical penalization137

·Bangerter filters138

·Surgery to treat the cause of the amblyopia139-141

·Acupuncture142,143

·Vision therapy144,145

下列療法已經(jīng)用于治療弱視：

·光學(xué)矯正52，126-128

·遮蓋59,60,129,130

·藥物性壓抑療法52,59,60,129,131-136

·光學(xué)的壓抑療法137

·Bangerter濾鏡138

·手術(shù)治療引起弱視的病因139-141

·針灸142，143

·視覺(jué)訓(xùn)練144，145

其中對(duì)于光學(xué)壓抑、針灸以及視覺(jué)訓(xùn)練， PPP認(rèn)為：或因缺乏隨機(jī)臨床試驗(yàn)證據(jù)支持，或因機(jī)制不清，或因存在爭(zhēng)論，這些療法“需要進(jìn)一步研究”。

圖5 光學(xué)壓抑療法（眼鏡片）

改變由側(cè)眼的光學(xué)矯正引起的視物模糊已被用于治療弱視眼，然而，這種技術(shù)的有效性有相當(dāng)大變異，還沒(méi)有經(jīng)過(guò)隨機(jī)的臨床試驗(yàn)驗(yàn)證（圖5）。

圖6

針灸對(duì)斜視性弱視的作用尚未進(jìn)行研究，針灸治療弱視的作用機(jī)制尚不清楚（圖6）。

圖7

Other eye exercises or forms of vision therapy have been promoted for the treatment of amblyopia as an adjunct to patching.144 However, there are insufficient cohort studies or randomized clinical trials to make a recommendation to use these techniques.145也有一些用眼球運(yùn)動(dòng)和視覺(jué)訓(xùn)練的方式來(lái)作為遮蓋的輔助療法治療弱視。然而，還沒(méi)有足夠的隊(duì)列研究或隨機(jī)臨床試驗(yàn)證明推薦這些治療方案是可行的（圖7）。

回到開(kāi)篇提出的問(wèn)題：弱視屈光矯正后是否還需要做視覺(jué)訓(xùn)練?

從弱視PPP中可見(jiàn)，目前最新的弱視臨床指南認(rèn)為，弱視訓(xùn)練是“未完全確認(rèn)，需要進(jìn)一步研究的”，有學(xué)者提出“生活就是最好的訓(xùn)練”。筆者聯(lián)想到：原來(lái)最早的弱視訓(xùn)練是“描紅、穿珠子、穿針……”，后來(lái)有弱視訓(xùn)練軟件——在電腦上給弱視患兒玩游戲……到了今天，手機(jī)、iPad都成為“弱視訓(xùn)練工具”了，玩游戲可是不枯燥，動(dòng)力十足呢，這種訓(xùn)練方式是否更容易堅(jiān)持呢？看來(lái)“生活就是最好的訓(xùn)練”有些道理。?