| Background:Glaucoma is one of the most common irreversible blinding eye diseases. Pathologically elevated intraocular pressure (IOP) is the main reason for the occurrence and development of glaucomatous optic nerve damage. IOP is an important indicator for the diagnosis and curative effect assessment of glaucoma and reducing IOP is currently the only treatment that have been proved to be effective for glaucoma. Thus, the measurement and monitoring of the IOP is crucial to the diagnosis and treatment of glaucoma. However, IOP has diurnal rhythm and long-term fluctuation like other vital signs parameters such as blood pressure, body temperature, pulse and so on. Several studies have shown that a single IOP measurement and regular daytime IOP fluctruation measurement can hardly objectively reflect the real situaion IOP of the patient. IOP is a biological indicator that changes dynamically and easily affected by various internal and external factors, for example, body condition, physiological changes, temperature, pressure, light and so on. Body position and exercise may also have a great effect on IOP. The influence of body positon changes before and after getting up and daily activities in the morning on IOP can reflect the influence of many factors on IOP, however, few articles have summerised these when review the past literatures. Research on the influence of body positon changes before and after getting up and daily activities in the morning on IOP can provide a reference to scientifical formulation of diurnal IOP measurement scheme. Because IOP has diurnal rhythm and long-term fluctuation and the peak and valley value of IOP appear mostly out of the work hours of daytime, regular measurement of daytime IOP fluctruaion can hardly objectively reflect the true IOP of patient. Only24hour (24h) IOP measurement can better reflect the IOP changes during the whole day and night, providing objective evidence for the early diagnosis of glaucoma and suspected glaucoma patients as well as the formulation and adjustment of therapeutic schedule. But standard24h IOP measurement (once every one hour) is inconvenient, it affects patients’ sleep and increases the risk of corneal injury and eye infections, moreover, it is difficult to be widely used clinically. The IOP measurement scheme, which can not only exactly reflect the peak, valley and fluctuation values of IOP and be relatively convenient, safe and easy, but also minimize the disturbance to patients’ sleep and be easily accepted by physicians and patients, worth to be analysed and discussed.The actually executive IOP measurement scheme is different between different areas nowadays. There is no unified national regulations that how to arrange time point and frequency of24h IOP. Some hospitals measure IOP in merely daytime, while some hospitals measure IOP on every2hours. Some hospitals measure IOP in sitting position in the daytime with a regular lumination, and in lying position during sleeping time in middle night under a dim light. Recently Ophthalmology Branch of Beijing Medical Association explored the scheme of diurnal IOP measurement, and two methods were put forward for choice on the basis of the conditions of patients. The first one was called the traditional position IOP measurement method with7 measuring time point (excluding measuring time points in the sleeping time at midnight) in sitting position with a regular lumination. The second one was called the habitual position IOP measurement method, which measured IOP every2hours; and the IOP during the daytime was measured with a Goldmann applanation tonometer in sitting position with a regular lumination while the IOP during the night sleeping time was measured with other tonometers in lying position under a dim light. It’s only a preliminary exploration rather than concrete rule or suggestion. On condition that basically meeting clinical needs, how we seek a diurnal IOP measurement method which can reduce the pain of the patients and operating difficulties of the doctors, and especially minimize the disturbance to normal biological rhythms and eye infection and tissue damage of ocular surface of the patients is an important clinical problems needed to be solved urgently.In recent one years, we mainly used modified24h IOP measurement method (scheme A) as IOP monitoring for the most patients in our hospital, and traditional24h IOP measurement method (scheme B) was still used in a small number of patients. Compared with scheme B, scheme A omitted the IOP measurement in night sleeping time points. In the first part of the project, a group of suspicious glaucomatous patients were measured the IOP in lying position before getting up,5minites after sitting up in sitting position and5to10minites after daily activities such as dressing and washing in the morning time in sitting position with a Icare tonometer in the process of24h IOP measurement.We mainly studied the effects of position changes before and after getting up in the morning and daily activities on IOP in suspicious glaucomatous patients. In the second part of this project, we compared the IOP curve datas measured by scheme A and B and proposed daytime IOP curve extracted from scheme A and proposed scheme A extracted from scheme B. It provides us with reference and ideas that seeking a kind of diurnal IOP measuring scheme that was not only satisfactory clinically, but also relative simple, safe, and bascically feasible.Objective:1. To study the influence on IOP of the postural change and daily activities in the early morning and provide a reference to scientifical formulation of diurnal IOP measurement scheme.2. To compare the detection ability of different IOP measurement scheme for the abnormal parameter, peak value and abnormal values, and provide a reference to seeking for a diurnal IOP measurement scheme which can meet the clinical needs and be reletively convenient, safe and feasible.Methods:1. Fifty-one cases (100eyes) with glaucoma or suspected glaucoma were waked up gently on5:30or6:30and measured the IOP in lying position before getting up,5minites after sitting up in sitting position (namely the IOP before activities) and5to10minites after daily activities such as dressing and washing in sitting position (namely the IOP after activities) in the morning time with a Icare rebound tonometer in the process of24h IOP measurement.2. Three hundred and eighty-eight patients (685eyes) with the characteristic of unimodal or bimodal IOP curve were screened out form the408patients (805eyes) with glaucoma or suspected glaucoma, and all these patients had received IOP measurement with scheme A or scheme B. The IOP of334patients(594eyes) were measured with Scheme A(eight measuring time points:9:30,11:30,14:30,16:30,18:30,22:00,6:00,8:00) while the IOP of54patients(91eyes) were measured with Scheme B(ten measuring time points:9:30,11:30,14:30,16:30,18:30,22:00,2:00,4:00,6:00,8:00). IOP was measured three times at each time point by a same doctor with a Goldmann applanation tonometer (GAT) and the three measurement results were averaged into a single data point for analyses. Formulate the "Proposed daytime IOP curve" from the data of scheme A and formulate the "Proposed scheme A IOP curve" from the data of scheme B. The data of IOP curve of4groups were compared for the detection ability of abnormal patients (eyes), peak value and abnormal value.Statistic methods:1. The IOP values of supine or sitting position and before or after getting up was compared by paired samples t test, and the correlation was analyzed by Pearson correlation coefficient.2. Chi-square test was used to compare the normal and abnormal results between different groups, Wilcoxon rank test was used to compare the detection ability of different groups for peak value and abnormal values. A p-value of less than0.05was regarded as statistically significant.Results:1. The mean of sitting IOP of51patients was (17.12±4.53) mmHg, which was significantly lower than the mean of supine IOP (19.14±5.51) mmHg with t=7.17P=0.000. There was a significant correlation between sitting and supine IOP with R=0.861, P=0.000. The mean of IOP after daily activity of51patients was (14.44±3.90) mmHg, which was significantly lower than the mean of IOP before daily activity (17.12±4.53)mmHg, there was a significant correlation between the IOP before and after daily activity with R=0.861, P=0.000.2. Among the334patients (594eyes) in scheme A group, the24h IOP curves of193patients (433eyes) were normal and141patients (161eyes) were abnormal. Among the334patients (594eyes) in the formulated daytime curve group, the24h IOP curves of188patients (379eyes) were normal and146patients (215eyes) were abnormal. There was statistical significance with X2=41.054, P=0.000. Among the54 patients (91eyes) in scheme B group, the24h IOP curves of32patients (59eyes) were normal and that of22patients (32eyes) were abnormal. Among the54patients (91eyes) in the formulated scheme A curve group, the24h IOP curves of36patients (65eyes) were normal and that of18patients (26eyes) were abnormal. There was not statistical significance between the formulated scheme A curve group, scheme A group and scheme B group with X2=0.63531, P=0.4254; X2=2.5261, P=0.1120respectively.3. Among the255eyes with a abnormal24h IOP curve,310peaks in the24h IOP curves was found in scheme A group,while207peaks in the24h IOP curves was found from the formulated daytime curve, there was a statistical significance between two groups with Z=-8.583, P=0.000. Among the32eyes with an abnormal24h IOP curve in scheme B group,42peaks in the24h IOP curves was found in scheme B group,while30peaks in the24h IOP curves was found from the formulated scheme A.There did not have statistical significance between the formulated scheme A curve group, scheme A group and scheme B group with Z=-1.833, P=0.067; Z=-1.302, P=0.193respectively.4. Among the175abnormal patients in scheme A group, the number of abnormal value in the24h IOP curves is1190,but the number of abnormal value in the24h IOP curves used the formulate the daytime curve is796, there were have statistical significance between two of the groups with Z=-3.821, P=0.000. Among the22abnormal patients in scheme B group, the number of abnormal value in the24h IOP curves is142,but the number of abnormal value in the24h IOP curves used the formulate the scheme A curve is132,there did not have statistical significance between the formulate the scheme A curve group, Scheme A group and scheme B group with Z=-0.248, P=0.084; Z=-0.042, P=0.967respectively.5. Only11cases (3.3%)19eyes (3.2%) in334cases (594eyes) completed a supplementary measurement of IOPs during night sleepping time due to the insufficient results by scheme A measurement for the clinical need, and the registration form shows that there were12patients did not completed a supplementary measurement of IOPs during night sleepping time as the doctor asked. So less than10%of the patients need to supplement the IOP in night sleepping time after a measurement of24h IOP curve with the scheme A clinically.Conclusion:1. The fact that a change of5mmHg in IOP can take place before and after getting up and daily activities in the morning time reminds us of paying more attention to this time of IOP measurement when we formulate a better scheme to measure the diurnal IOP. Moreover, the standard to determine the result of24h IOP curve must be studied and modificated if the concept of habitual position to the curve of diurnal IOP measurement was introduced2. Acording to the data (abnormal cases, eyes, peak value and the ability outlier detection) of the four different scheme of24h IOP curve measurement, taking these factors such as safety, convenient, posture and activities influence on the measurement result into account, scheme A (not contains the two time points at night sleepping time) can be used as the first choice in most patients. It is a relatively scientific and reasonable clinical train of thought for the minority of diurnal IOP measurement, to make the first measurement with a modified scheme A, and completed a supplementary measurement of IOPs during night sleepping time as soon as possible when the result of the first measurement can not meet the clinical need in some cases. |
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