视网膜静脉搏动的发生机制及其临床应用价值

自发性视网膜静脉搏动(SVPs)可以在90％的正常人群中观察到,表现为视盘上的一条或多条视网膜静脉节律性的轻微收缩或扩张.国外多项研究表明,SVPs可用于颅内压监测及青光眼的诊断和随访,而目前国内尚未对这一现象进行研究和应用.尽管有关SVPs的发生机制存在争议,但其潜在的临床应用价值日益受到关注.就SVPs发生机制的研究现状及其测定方法和临床研究等方面的最新进展进行综述.     

Combined central retinal artery-central vein obstruction

The cases of 23 patients with unilateral combined central retinal artery-central retinal vein obstruction are described. Criteria for the abnormality included: a history of relatively sudden visual loss; superficial retinal whitening in the posterior pole in combination with a cherry spot; and intraretinal blood, generally associated with dilated and/or tortuous retinal veins. In five instances (22%) the obstructions developed after retrobulbar injection. Among the 21 patients with followup for at least 6 months, or until the onset of neovascularization of the iris, 17 (81%) developed rubeosis iridis.Late histopathology was obtained in two eyes. Hemorrhagic necrosis of the retina was observed in some areas of the posterior pole and attenuation of the inner retinal layers, similar to that seen with late central retinal artery obstruction, was noted elsewhere. Periphlebitis of the central retinal vein within the optic nerve was found in each case.     

Neovascular glaucoma following central retinal vein obstruction

The results of a prospective clinical and fluorescein angiographic study of 155 patients with central retinal vein obstruction (CRVO) were analyzed to identify risk factors contributing to the subsequent development of iris neovascularization (NVI) and neovascular glaucoma (NVG). Of 144 untreated eyes, 20% developed NVG. The eyes were classified as having either an ischemic or a hyperpermeable type of CRVO according to the extent of retinal capillary nonperfusion demonstrated by the initial fluorescein angiogram. The risk of developing NVG was found to be approximately 60% in those eyes with extensive retinal ischemia. None of the 22 eyes with an ischemic CRVO treated with panretinal photocoagulation (PRP) prior to the onset of NVI developed NVG.     

Management of the open angle glaucoma in patients with central/hemicentral retinal vein occlusions

AIM: To prospectively assess the cumulative prevalence and management of open angle glaucoma (OAG), including primary open angle glaucoma (POAG) with high and normal-pressure, as well as pseudoexfoliative glaucoma (PEXG), in patients with central/hemicentral retinal vein occlusions (RVOs) over a 3-year follow-up period. METHODS: The study encompassed 57 patients with unilateral acute central/hemicentral RVOs. A complete ophthalmic examination of both eyes was undertaken for all patients. Patients with OAGs associated with central/hemicentral RVOs were treated with the current ocular hypotensive medications used worldwide and/or surgery and aimed to reduce the intraocular pressure (IOP) by 30% from baseline values for the 3 OAG forms existing in our series. The cumulative prevalence of OAG and the efficacy of treatment were evaluated. RESULTS: OAG was observed in 3 clinical forms, namely, POAG with increased IOP in 4 patients, POAG with normal IOP in 3 patients, and PEXG in 3 patients. The cumulative prevalence of OAG was 19.6% (95%CI: 8.7-30.5). Using available ocular hypotensive medications (8 patients) and trabeculectomy (2 patients), the IOP decreased significantly from 24.3±4.36 mm Hg to 16.55±2.85 mm Hg, a reduction of 31.89% compared with baseline values. Glaucoma progression was not detected in any of the cases. CONCLUSION: The high value of the cumulative prevalence of OAG is a risk factor for the development of venous occlusion. The treatment of glaucoma prevented its progression over a follow-up period of 3y.     

视网膜中央静脉阻塞合并原发性青光眼临床分析

本文１５６例视网膜中央静脉阻塞中，有１７例同时或先后发生了原发性青光眼（１０９０％）。其中开角型青光眼１４例，闭角型青光眼３例，全部青光眼病人眼压高于４７６ｋＰａ以上。Ｃ／Ｄ值≥０７。闭角型青光眼房角均为窄Ⅲ—窄Ⅳ。且有部分房角粘连性闭合。视网膜中央静脉阻塞眼有３４％视力≥０２，而视网膜中央静脉阻塞合并原发性青光眼只有２４％视力≥０２，在视力指数—无光感病人中，视网膜静脉阻塞眼占２２％，视网膜中央静脉阻塞合并原发性青光眼则占５８％。本文结果显示原发性青光眼对视网膜中央静脉阻塞病人视力有严重影响。我们对视网膜中央静脉阻塞与原发性青光眼的关系进行了讨论。     

视网膜中央静脉阻塞治疗研究进展

视网膜中央静脉阻塞是临床上常见的视网膜疾病,因严重的并发症导致视力下降甚至失明,到目前为止尚无针对其病因的确切有效的治疗方法。近年来激光光凝、激光诱导视网膜脉络膜吻合、视网膜静脉t-PA注射、玻璃体腔内注射、放射状切开等手术方法为视网膜中央静脉阻塞带来了新的观念,我们将对上述几种方法的实验和临床研究作简要综述。     

康柏西普联合全视网膜激光光凝治疗CRVO继发新生血管性青光眼

目的：探讨康柏西普联合全视网膜激光光凝(panretinal photocoagulation,PRP)治疗视网膜中央静脉阻塞(central retinal vein occlusion,CRVO)继发新生血管性青光眼(neovascular glaucoma,NVG)的疗效。

方法：本组观察对象为2014-05/2017-05于我院眼科治疗的CRVO继发NVG患者100例100眼,现回顾性分析其病历资料,将采用青光眼滤过性手术联合PRP治疗的50例患者设为对照组,在此治疗基础上加用玻璃体腔注射康柏西普的50例患者设为观察组。比较术前、术后7d,1、3、6mo最佳矫正视力(best corrected visual acuity,BCVA),并采用非接触式眼压计比较各时期眼压,裂隙灯检查新生血管消退情况并结合眼压等判断手术效果,随访6mo记录术后复发率及并发症发生情况。

结果：两组患者术后1、3、6mo BCVA趋于稳定,术后BCVA与术前比较,组间各时间点比较差异无统计学意义(P>0.05); 两组术后7d,1、3、6mo眼压均显著低于术前,术后7d,1mo观察组显著低于对照组,差异有统计学意义(P<0.05),术后3、6mo组间比较差异无统计学意义(P>0.05); 观察组手术成功率为100%,与对照组(92%)比较差异具有统计学意义(P<0.05),观察组手术完全成功率为84%,显著高于对照组(66%), 差异有统计学意义(P<0.05); 观察组前房出血及复发率显著低于对照组,差异有统计学意义(P<0.05),两组患者浅前房、低眼压发生率差异无统计学意义(P>0.05)。

结论：术前玻璃体腔注射康柏西普联合PRP治疗CRVO继发NVG眼压恢复时间更短,手术效果更优,能控制前房出血并降低复发率。     

视网膜中央静脉阻塞黄斑水肿的治疗新进展

视网膜中央静脉阻塞(central retinal vein occlusion,CRVO)是一种常见的视网膜血管性疾病,黄斑水肿是其主要并发症也是导致视力下降的主要原因。目前临床广泛应用及研究的热点主要有激光光凝,玻璃体注药治疗:曲安奈德、血管内皮生长因子抗体,手术治疗:放射状视神经切开术等。     

影响视网膜静脉阻塞及黄斑中心视网膜厚度改变的因素分析

目的:分析不同危险因素对视网膜静脉阻塞(RVO)发病的影响,同时观察并研究不同因素对黄斑中心视网膜厚度(CRT)的影响。方法:回顾性研究。收集2016-09/2019-04我院眼科就诊的RVO患者79例79眼作为RVO组,并根据CRT是否大于369μm将其分为高CRT组(26眼)和低CRT组(53眼)。收集同时期入院拟行白内障手术患者59例59眼作为对照组。统计分析RVO发病危险因素以及影响CRT改变的因素。结果:与对照组相比,RVO组中高血压、颈动脉斑块以及高同型半胱氨酸血症有差异(P<0.05)。不同CRT分组间分析结果则显示中央部位阻塞和吸烟史有差异(P<0.05)。结论:高血压、颈动脉斑块、高同型半胱氨酸血症是RVO发病的危险因素。而中央部位阻塞以及吸烟史是影响CRT厚度改变的因素。     

Central retinal vein occlusion in pseudoexfoliation of the lens capsule

In surveying an extensive group of patients with unilateral pseudoexfoliation of the lens capsule certain interesting points emerged, particularly on the incidence of central retinal vein occlusion in this condition,and perhaps in glaucoma also. A total of 284 patients with unilateral pseudo-exfoliation of the lens capsule were examined clinically after an ophthalmic and general history were taken. Mean intraocular pressure (IOP) was 30.9 mmHg in the affected eye and 18.1 mmHg in the unaffected eye. Central retinal vein occlusion occurred in 10 affected eyes but no unaffected eyes and always in affected eyes with a rise in IOP. Average IOP in the affected eye with central retinal vein occlusion was 37.5 mmHg (range 26-54 mmHg);in the unaffected fellow eye it was 18.0 mmHg (range 11-28 mmHg). Although the process involved in producing pseudo-exfoliation of the lens capsule may contribute to the precipitation of central retinal vein occlusion, these findings suggest the rise in IOP is the more important cause. This may also be so in other forms of glaucoma.     

A randomised prospective study of outpatient haemodilution for central retinal vein obstruction

Purpose: Central retinal vein obstruction (CRVO) has significant visual morbidity. We prospectively evaluated an outpatient haemodilution (HD) regimen for CRVO.
Methods: We recruited 59 patients with CRVO of less than three months' duration and visual acuity (VA) worse than or equal to 6/9.5. Thirty patients underwent HD (packed cell volume of <0.35, 12 weeks); there were 29 controls and follow-up was for six months.
Results: Incidence rates for VA improvement ( P =0.708) and rubeosis iridis ( P =0.619) between the two groups were not different. The incidence rate of VA deterioration was 5.315 times higher with HD ( P =0.035, Cox Proportional analysis).
Conclusion: This data does not support the previous studies on haemodilution.     

氩激光治疗视网膜中央静脉阻塞的时机探讨

目的:探讨氩激光治疗视网膜中央静脉阻塞(central retinal vein occlusion,CRVO)的时机。方法:根据CRVO发病后至接受激光治疗的时间不同分为3组,A组为CRVO发生后4~8wk共23例23眼,B组为CRVO发生后12~16wk共9例9眼,C组为CRVO发生20wk以后共6例6眼。激光治疗方法分为黄斑区格栅样光凝,局灶性视网膜光凝及全视网膜光凝。结果:2a后A组视力>0.3者为17眼占74%;B组视力>0.3者为4眼占44%;C组视力>0.3者仅1眼占17%,2例发展成为新生血管性青光眼(NVG)。结论:CRVO发生后早期光凝治疗对视力的恢复有较好的效果,晚期光凝治疗主要是预防并发症的发生。     

Ocular neovascularization with retinal vascular occlusion-III. Incidence of ocular neovascularization with retinal vein occlusion

A prospective natural history study was conducted in 721 eyes with various types of retinal vein occlusion (RVO) to determine the incidence of various types of ocular neovascularization (NV) and the factors that influence the development of ocular NV. The material was 360 eyes with central retinal vein occlusion (CRVO), 97 eyes with hemi-CRVO, and 264 eyes with branch retinal vein occlusion (BRVO); these cases were further subdivided into six groups for logical data analysis: nonischemic CRVO (venous stasis retinopathy-VSR, 282 eyes), ischemic CRVO (hemorrhagic retinopathy-HR, 78 eyes), hemi-VSR (66 eyes), hemi-HR (31 eyes), major BRVO (191 eyes) and macular BRVO (73 eyes). Ocular NV attributable to RVO was seen only in HR, hemi-HR, and major BRVO. In HR the anterior segment was the major site of NV, with iris and angle NV and neovascular glaucoma (NVG), while in hemi-HR and major BRVO the retina and optic disc were the major sites of NV. The principal factor influencing the development of ocular NV in RVO seems to be the severity and extent of retinal ischemia, while duration of follow-up since onset also plays an important role in determining the incidence of ocular NV. The findings and subject of ocular NV in RVO are discussed in detail along with a review of the pertinent literature.     

The venous closing pressure in central retinal vein obstruction

Objective: To assess the rate of change in the central retinal venous closing pressure in central retinal vein obstruction over time, and its relationship to visual acuity improvement and the development of rubeosis iridis.
Methods: Fifty patients presenting with central retinal vein obstruction of less than three months' duration, between the ages of 40 and 80 years, were reviewed prospectively. The central retinal venous closing pressure was measured by digital ocular compression. Patients were discharged from the study after the six-month visit.
Results: All patients had elevated venous closing pressure at presentation, whereas at six months only 24 patients had persistent elevation. Of 16 patients with lowering of the venous closing pressure within four months of onset of central retinal vein obstruction, 11 (69%) had two or more lines of visual acuity improvement. Only two of 10 patients (20%) developing lowering of the venous closing pressure thereafter had visual improvement. No patient developed rubeosis iridis after the venous closing pressure lowered.
Conclusion: The central retinal venous closing pressure is raised in central retinal vein obstruction to about central retinal arterial diastolic pressure, and is its pathognomonic sign. This sign is easily elicited via digital pressure on the eyelid, and has prognostic significance for visual acuity improvement and the development of rubeosis iridis.     

放射状视神经切开治疗视网膜中央静脉阻塞

视网膜中央静脉阻塞是常见的致盲性眼病。目前许多治疗措施主要是针对黄斑水肿或新生血管性青光眼等并发症,方法包括药物、激光和手术。我们针对放射状视神经切开术做简单综述。     

康柏西普联合PRP治疗视网膜中央静脉阻塞继发早期新生血管性青光眼

目的：对比研究玻璃体腔注射康柏西普联合全视网膜激光光凝(PRP)与单纯全视网膜激光光凝对视网膜中央静脉阻塞(CRVO)继发Ⅰ、Ⅱ期新生血管性青光眼治疗效果的临床观察。

方法：采取临床病例对照研究方法。将2014-01/2019-03在我院诊断为CRVO继发Ⅰ、Ⅱ期新生血管性青光眼患者60例60眼,随机分为联合治疗组和单纯治疗组。联合治疗组采用康柏西普联合全视网膜激光光凝治疗; 单纯治疗组采用单纯全视网膜激光光凝治疗。观察两组患者治疗前、治疗后1wk,1、3、6、9mo的视力、眼压、虹膜新生血管、房角新生血管的情况,进行统计学分析。

结果：不同时间点两组房角及虹膜新生血管数量和视力、眼压有差异(F=154.992、92.519、30.696、82.374,均P<0.001),联合治疗组在治疗开始后1wk的各项指标均出现明显好转,并维持至治疗结束。而单纯治疗组在给予治疗后数据改善程度不及联合治疗组(F=50.870、24.265、13.125、11.829,均P<0.001)。

结论：玻璃体腔注射康柏西普联合全视网膜激光光凝治疗CRVO继发Ⅰ、Ⅱ期新生血管性青光眼疗效优于单纯全视网膜激光光凝治疗,效果显著并持续维持。     

Ischemic retinal vein occlusion: characterizing the more severe spectrum of retinal vein occlusion

Retinal vein occlusion (RVO)-including central RVO, branch RVO, and hemicentral and hemispheric RVO—is the second most common vascular cause of visual loss, surpassed only by diabetic retinopathy. The presence and extent of retinal ischemia in RVO is associated with a worse prognosis. On this basis, most previously conducted studies considered ischemic retinal vein occlusion (iRVO) and non-iRVO as separate entities based on set thresholds of existing retinal ischemia as determined by fundus fluorescein angiography. Other diagnostic technologies have been used specifically in the differentiation of ischemic central retinal vein occlusion and nonischemic central retinal vein occlusion. To date, there is no fully accepted definition for iRVO. Some clinicians and researchers may favor establishing a clear differentiation between these forms of RVO; others may prefer not to consider iRVO as a separate entity. Whatever the case, retinal ischemia in RVO confers a higher risk of visual loss and neovascular complications; thus, it should be determined as accurately as possible in patients with this disease and be considered in clinical and experimental studies. Most recently conducted clinical trials evaluating new treatments for macular edema secondary to RVO included none or only few patients with iRVO based on previous definitions (i.e., few patients with sizeable areas of retinal ischemia were recruited in these trials), and thus it is unclear whether the results observed in recruited patients could be extrapolated to those with retinal ischemia. There has been scant research aiming at developing and/or testing treatments for retinal ischemia, as well as to prevent new vessel formation as a result of RVO. We provide a detailed review of the knowledge gathered over the years on iRVO, from controversies on its definition and diagnosis to the understanding of its epidemiology, risk factors and pathogenesis, the structural and functional effects of this disease in the eye and its complications, natural history, and outcomes after treatment. In each section, the definition of iRVO used is given so, independently of whether iRVO is considered a separate clinical entity or a more severe end of the spectrum of RVO, the information will be useful to clinicians to determine patient's risk, guide therapeutic decisions, and counsel patients and for researchers to design future studies.     

Ocular hypertension in patients with central/hemicentral retinal vein occlusions: cumulative prevalence and management

AIM: To prospectively evaluate the cumulative prevalence and the management of ocular hypertension (OH) in patients with unilateral acute central/hemicentral retinal vein occlusions (C/HCRVOs) over the course of 3y. METHODS: The study included 57 patients with unilateral acute C/HCRVOs. All patients underwent a comprehensive ophthalmological examination of both eyes. OH associated with C/HCRVO in patients showing a score >5% for the risk of conversion to primary open angle glaucoma (POAG) was treated with OH medication. The treatment aimed for a decrease in intraocular pressure (IOP) to <21 mm Hg with a >22% reduction from the initial values. The cumulative prevalence of OH and the effectiveness of treatment assessed by the cumulative prevalence of conversion from OH to POAG, were estimated. RESULTS: Fifteen patients had OH associated with C/HCRVOs, the cumulative prevalence of OH was 29.4% (95% confidence interval, 16.9-41.9). The mean value of the risk score of OH conversion to POAG for the 5 subsequent years was 11.7%±5.4%. The IOP significantly decreased from 25.67±2.16 mm Hg to 18.73±2.96 mm Hg. None of the OH patients converted to POAG during the follow-up period. CONCLUSION: The increased cumulative prevalence of OH in C/HCRVO patients indicates that OH is a risk factor for the appearance of venous occlusion. Patients with OH associated with C/HCRVO must be considered to be at high risk for conversion to POAG. Treatment with OH medications prevented conversion to POAG during the 3-year follow-up.