缺血型视网膜静脉阻塞(RVO)是一种机制复杂的难治愈性眼科疾病.发病过程呈现出早、中、后期不同的临床特点.临床上,张南根据不同时期的特点,中西医结合分期治疗,早期中药治以凉血止血、散瘀行气,西医治疗基础病,消除血栓;中期中药治以活血化瘀、行气导滞,西医配合激光治疗;后期活血化瘀、软坚散结,西医促进视网膜功能恢复,清除机化物;如果存在黄斑水肿,及时进行玻璃体腔注药术,中药健脾利湿去水肿.此外,张南强调基础病在缺血型RVO治疗和愈后中的重要作用,因此,缺血型RVO患者应格外重视基础病的预防护理,防止病情反复发作.

中医药防治疫病经验丰富且可靠.儿童因其生理病理特殊性,其发病机制、防治方案均有别于成人.COVID-19由新型冠状病毒引起,儿童以"风""寒""热""湿"邪为重要特征,病情较重,且传染性强.张涤教授基于中医学三因制宜及卫气营血辨证体系,针对儿童生理病理特点及地域特点,结合其临床证候表现,认为COVID-19病位主要在肺(上焦),可涉及胃肠(中焦).预防上,未病先防,培正避害;健脾补肺,平衡阴阳.治疗上,常见证型有风寒证、风热证、表寒里热证、疫邪犯胃证、气虚外感证,分证治之.为儿童COVID-19的防治提供参考与借鉴.

目的:观察视清饮对阴虚燥热型非增殖期糖尿病视网膜病变(NPDR)视网膜神经的作用.方法:选取2018年1月至12月就诊于北京中医药大学东直门医院眼科的60例阴虚燥热型NPDR患者,随机分为试验组和对照组,每组30例.两组均控制血糖和基础疾病水平,试验组加予口服视清饮中药颗粒每日2次,疗程4周,分析两组治疗前后的中医症状、最佳矫正视力、视野、眼底情况、光学相干断层扫描和电生理指标的变化.结果:治疗后,试验组的眼底疗效及中医症状评分改善优于对照组(P＜0.01);试验组组内加权视野指数和光学相干断层扫描视盘旁全周及下方象限视网膜神经纤维层厚度改善(P＜0.05,P＜0.01).结论:视清饮对阴虚燥热型NPDR的眼底及症状有一定的改善作用.

糖尿病视网膜病变(DR)是糖尿病最严重的并发症之一,随着对疾病研究的不断深入,玻璃体腔抗血管内皮生长因子(VEGF)药物注射治疗成为糖尿病性黄斑水肿(DME)主流治疗方案.文章总结了许家骏教授运用中医微型癥瘕理论在DME患者围手术期进行治疗的思路和方法,针对患者不同的眼底表现及全身症状辨证,在益气养阴的基础上治以祛痰、解郁、清热、化瘀,祛邪扶正,并联合玻璃体腔抗VEGF药物注射,改善患者眼部及全身症状,临床疗效较佳,可进一步推广.

1 临床资料 患者,女,73岁.因“右上睑缘肿物1年,加重2个月”于2016年1月6日至东直门医院就诊.既往高血压病史20余年,无过敏史.1年前无明显诱因右上睑缘长一肿物,无疼痛不适,未予治疗.2个月前自觉肿物生长加快,遂来诊.查:右上睑缘一柱状肿物,基底部下缘位于睫毛根部,距睑缘灰线约2.5 mm,基底部直径约3 mm,肿物高度约10 mm,表面可见血管扩张,无毛发,无压痛,无破溃.双眼视力0.8,右眼眼压18 mmHg(1 mmHg=0.133 kPa),左眼16mmHg.

文章总结了许家骏主任中西医结合治疗黄斑水肿的思路、方法和经验,阐述了其对黄斑水肿中医病因病机的认识.脾虚肝旺在黄斑水肿患者病程中一直存在,在中医辨证治疗黄斑水肿的基础上应佐以柔肝补脾的方法,并结合美国眼科学会2015年临床指南,提出应中西医联合治疗黄斑水肿以期达到更好的临床治疗效果.

目的 对比观察中医辨证治疗和常规治疗小儿秋季腹泻45例的临床疗效.方法 90例纳入观察的小儿秋季腹泻患者随机分为观察组和对照组,每组45例,对照组口服蒙脱石散、枯草杆菌二联活菌颗粒和利巴韦林颗粒,观察组同时予以中医辨证用药治疗.结果 两组患者治疗周期均未超过7d,无病情加重情况,但观察者患儿的止泻、止吐、体温恢复正常和脱水纠正时间均明显短于对照组,差异均有统计学意义(P＜0.05).结论 中医辨证用方治疗小儿秋季腹泻疗效确切,优于单纯西医治疗,值得临床推广应用.

肺炎喘嗽是小儿时期常见的肺系疾病,临床以发热、咳嗽、痰壅、气促、鼻煽为主要证候特点.张涤教授在临床中运用中医药治疗肺炎喘嗽,以开肺化痰、止咳平喘为主法,且临证用药注重顾护脾胃,临床获满意疗效.

根据中医五轮学说,角膜归属于黑睛,属肝,故自古医者多从肝论治角膜疾病.而根据多年临证经验,笔者发现角膜浅层病变从肝论治往往未能取得很好的效果,而从肺论治的效果却是比较理想的.文章就此从角膜的解剖、生理,从五行生克及角膜浅层病变的病因探讨其与肺的密切关系,并辅以临床医案,阐述临证多采用辛凉透表、清热解毒、疏散肺邪、清肝利胆、退翳明目的方法治疗,以飨同道.

1 临床资料 男性,34岁.以进行性视力下降伴间断眼胀17年为主诉,于2017年3月15日就诊于北京中医药大学东直门医院.患者曾先后诊断为双眼视神经萎缩,原发性空蝶鞍综合征伴有良性颅压升高,否认手术史.既往无特殊病史,否认家族性遗传病史.全身查体:体型微胖,体重指数(BMI)24.49 kg/cm2,血压123/79 mm Hg(1 mm Hg=0.133 kPa),未见内分泌功能异常症状,Babinski征未引出.眼部检查:视力双眼数指/30 cm,眼压右眼31 mm Hg,左眼33 mmHg.

目的:探讨滋阴润燥法治疗阴虚内燥型2型糖尿病(T2DM)干眼症的临床疗效及安全性.方法:阴虚内燥型T2DM干眼症患者60名(120眼),随机分为中药组30例(60眼)和对照组30例(60眼).中药组用滋阴润燥法方内服外熏相结合,对照组以聚乙烯醇滴眼液点眼,每日4次.用药0、14、28d时记录患者眼部自觉症状评分、泪膜破裂时(BUT)、泪液分泌试验(SIT)、泪荧光素染色(FL)、角膜知觉检测评分,并进行组内、组间对比.分析总结滋阴润燥法对阴虚内燥型T2DM干眼症的临床疗效及安全性.结果:中药组的总有效率显著优于对照组(P＜0.05).两组均未出现药物不良反应.两组患者客观指标比较:中药组治疗14d时SIT、角膜知觉优于对照组(P＜0.05,P＜0.01),治疗28d时,仅SIT有统计学意义(P＜0.05).自身用药前后对比:中药组BUT、SIT、FL均有统计学意义(P＜0.05,P＜0.01),对照组BUT、SIT有统计学意义(P＜0.05,P＜0.01).两组患者眼部症状评分比较:治疗14d时异物感对照组优于中药组(P＜0.01),治疗28d时烧灼感、视疲劳、眼痒、眼红中药组优于对照组(P＜0.01);自身用药前后对比:中药组干涩感、烧灼感、视疲劳、眼痒、畏光、眼红显著改善(P＜0.05,P＜0.01),对照组干涩感、异物感、视疲劳显著改善(P＜0.01).结论:滋阴润燥方能有效治疗阴虚内燥型T2DM性干眼症,且安全性较高.不仅能提高患者的泪膜稳定性,增加基础泪液分泌,还能在一定程度上对角膜上皮进行修复,在治疗中对患者的自觉症状有较好的改善作用,总体疗效优于对照组.

借助循证医学的方法,根据临床上3例患者的治疗方案,对美国眼科学会于2016年发布的临床指南中原发性闭角型青光眼及其疑似患者的管理进行回顾性总结和探讨.针对临床上最为常见的两种干预方式激光虹膜切开术和白内障超声乳化术,集中讨论两种处理方式的优势和潜在风险,意在灵活运用新版指南.初步探讨原发性闭角型青光眼的早期中药干预,尽早保护视神经及视功能.原发性闭角型青光眼的早期干预应充分评估患者情况,结合全身状态辨证论治,选择精准化、个性化的中西医结合治疗方案.

Objective:To evaluatetheclinical effect of Shiqing Drink on cataract of stasis-heat blocking collaterals with non-proliferative diabetic retinopathy (NPDR),and to explore its effect on the level of ICAM-1 in aqueous humor and macular retinal thickness.Methods:Sixty cases of cataracts of stasis-heat blocking collaterals with NPDR were selected and randomly divided into Chinese medicine group (Shiqing Drink,group A),Western medicine group (calcium dobesilate capsule,group B),and 35 patients were randomly selected who underwent cataract surgery and without diabetes as control group (Group C).Group A and B were given corresponding drug treatment,which the course of treatment was 1 months,while group C had no special treatment.Three groups of patients with surgery were taken the aqueous humor.ICAM-1 level in theaqueous humor and macular retinal thickness changes before and after the treatment in the 3 groups were observed.Results:①Macular retinal thickness:Group A after treatment decreased than that before treatment,and the difference was statistically significant (P＜0.05);there was no obvious change in B and C groups before and after treatment;②DR fundus lesions:after treatment,the total effective rate of A (66.7％) was better than group B (P＜0.01);③ICAM-1 level in aqueous humor:group C＜A＜B,and there were significant statistical differences (P＜0.01);④Clinical symptoms of Chinese medicine:the curative rate of group A was significantly higher than that of group B,and there was significant statistical difference (P＜0.01).Conclusion:In treating stasis-heat blocking collaterals type NPDR,Shiqing Drink can regulate the level of ICAM-1 in aqueous humor,effectively reduce the macular retinal thickness and improve the fundus diseases.It also can significantly improve the typical symptoms of stasis-heat blocking collaterals.

1 临床资料 病例1 患者女性,53岁.因患糖尿病20年,要求检查眼底情况,于2017年5月27日就诊于北京中医药大学东直门医院眼科.患者自述既往近视,否认家族遗传性疾病.眼部检查:视力右眼-1.25 DC×3=0.8,左眼-0.25 DS=0.8;非接触眼压(NCT):右眼 13 mm Hg,左眼12 mm Hg (1 mm Hg=0.133 kPa).

Thyroid associated ophthalmopathy (TAO) is a common orbital disease.The main symptoms include eyelid retraction,conjunctival congestion and edema,orbital pain,exophthalmos,eyelid lag or invagination,eye movement disorder caused by extraocular muscle involvement,diplopia,exposure keratitis and optic nerve involvement.It is a disease that needs to be further explored for both Chinese and western medicine.The following is a TAO patient with diplopia failed in hormone therapy and the idea of wind-oriented treatment combined with acupuncture is taken,whose therapeutic effect is satisfactory.That may provide a new point for the TAO's treatment.

目的:研究白内障超声乳化术中针药复合麻醉的镇痛效果及安全性.方法:纳入2015年7月-2016年3月行白内障超声乳化手术的患者(90眼),将其随机分为表面麻醉组(A组)、球后麻醉组(B组)、针药复合麻醉组(C组),每组30眼.A组行表面麻醉;B组球后注射;C组行针刺合谷、太冲联合表面麻醉.分别记录术前(T0)、剪结膜囊时(T1)、虹膜穿刺时(T2)、超声乳化时(T3)、晶体植入时(T4)、手术结束时(T5)6个时点患者术中生命指标,观察并记录术中并发症、眼球灵活度,并于术后评估术中麻醉满意度.结果:C组术中生命指标较A组、B组稳定,疼痛发生率低,并发疗发生率低,术后麻醉满意度(P＜0.05).结论:白内障超声乳化术中针刺合谷、太冲,可起到镇静止痛,减轻应激反应的作用,患者镇痛满意度也最高.

Ophthalmology of Chinese medicine focuses on the combination of local differentiation syn-drome and integral differentiation syndrome,so in clinical practice systemic manifestation with tongue, pulse and local signs are equally important.Now,when the teachers give the lessons linked to fundus manifestations of diabetic retinopathy,what they can do is only simple description and explanation with or without pictures of fundus.And the college students are lack of intuitive feelings and hard to understand, who can only learn by rote and forget quickly.We attempt to combine classification of syndrome differen-tiation,DR images of fundus,with optical coherence tomography (OCT)images.The improvement in teaching both keeps consistent with the textbooks,and shows the students intuitive fundus manifestation of diabetic retinopathy corresponding to each syndrome type,which improves the students’learning enthusi-asm.

张涤系湖南中医药大学第一附属医院儿科主任医师,教授,硕士研究生导师,名中医,享受国务院政府特殊津贴专家,2009年被评为全国医药卫生系统先进个人.张涤教授从事中医儿科临床工作十余年,精通中医古典医籍,具有较高的专业理论水平,临床中注重发挥中医辨证与辨病结合的诊疗特色,辨证施治,病证结合,内外兼治,遣方用药精谨,在治疗小儿呼吸系统、消化系统疾病等方面逐渐形成了自己的特色和优势.

OBJECTIVE To verify the clinical efficacy and safety performance of the Thunder-fire moxibus-tion. according to medical technical operation scheme of traditional Chinese medicine clinical validation work re-quirements of Chinese Medicine Administration Bureau. METHODS A foresight, multicenter and self control clini-cal research project was designed, and a cooperative group was set up by Dongfang Hospital, Beijing Hospital of TCM and Dongzhimen Hospital. Each hospital with 30 dry eye cases was treated by Zhaoˊs thunder-fire moxibustion of Chongqing, once a day, 4 weeks treatment. Observed the objective indicators like the scores of clinical synptoms, tear film break-up time, schirmer test and cornea fluorescein staining, the statistical analysis was made at the end. ESULTS The effective rate of the thunder-fire moxibustion was 63%~75% in improving the dry feeling, foreign body sensation and asthenopia, while the effective rate was 38.9% in burning sensation and redness. CONCLU-SIONS To the dry-eye which was characterized by dry feeling, foreign body sensation and asthenopia, the therapeu-tic effect of thunder-fire moxibustion was obvious, while to the over evaporation dry-eye which was characterized by burning sensation and redness, the therapeutic effect was not significant.

张涤系湖南中医药大学附属第一医院硕士生导师,主任医师,教授,湖南省名中医,享受政府特殊津贴专家,2012年湖南省白求恩奖获得者,精通中医古典医籍.张师从事中医儿科临床工作10余年,治疗小儿疱疹性咽峡炎有独特疗效,现介绍如下. 1 诊断标准 西医诊断标准参照《诸福棠实用儿科学》(第6版).①病患接触史;②骤起发热,伴有厌食、咽痛、吞咽困难,亦可有呕吐、腹痛、头疼;③咽部出现散在性丘疱疹,直径1～3mm,有红晕,破溃形成浅溃疡,一般不超过12个.丘疱疹可见于软腭、悬雍垂、扁桃体,少数亦见于外阴部,但时间于齿龈及颊黏膜;④白细胞总数正常或偏低;⑤咽部分泌物病毒分离或桥酶标法检测提示柯萨奇病毒感染.