全身应用皮质类固醇激素致中心性浆液性脉络膜视网膜病变的临床特征

目的 探讨全身应用皮质类固醇激素致中心性浆液性脉络膜视网膜病变（CSC）的临床特征,指导临床诊断及治疗。方法 回顾性病例研究。分析经眼底检查、荧光素眼底血管造影（FFA）及光学相干断层扫描（OCT）确诊并结合全身疾病诊断为全身应用皮质类固醇激素致CSC 12例患者的临床资料。结果 12例患者均为双眼发病。眼底检查见视网膜后极部均有神经上皮脱离,伴有色素上皮脱离者6眼,伴有视网膜色素上皮多发性萎缩2眼,伴有黄色纤维素样渗出14眼,伴有大泡性视网膜脱离4眼。FFA后极部见单个渗漏点4眼,多个渗漏点20眼;伴有色素上皮萎缩条带2眼,伴有视网膜下大量积液4眼。OCT检查提示24眼存在单发或多发的神经上皮脱离伴/不伴有色素上皮脱离,其中6例患者有神经上皮脱离伴下方高反射信号。12例患者中,肾脏移植术后2例,多发性硬化3例,系统性红斑狼疮2例,肾病综合征2例,脱髓鞘疾病1例,另外2例患者因发热或者其他原因在当地输注过大剂量激素。结论 全身应用皮质类固醇激素致CSC对患者视力的损害极大,其典型的眼底特征可帮助诊断,对此类患者应定期进行眼底检查,便于早期发现,避免出现不可逆的视力损害。     

误诊为中心性浆液性脉络膜视网膜病变的原因分析

目的 分析孔源性视网膜脱离、原田病误诊为中心性浆液性脉络膜视网膜病变（CSC）的原因.方法 2001年1月～2006年10月所遇19例（19只眼）误诊为中心性浆液性脉络膜视网膜病变患者.孔源性视网膜脱离误诊为CSC15例,误诊时间2～40 d.原田病误诊CSC4例,患者均为女性,误诊时间分别为1～5 d.4例患者均为双眼视力突然下降,伴有头痛.结果 15例孔源性视网膜脱离患者明确诊断后,均行视网膜复位术.现随访3个月～5年,视网膜在位 4例原田病患者,给予大剂量糖皮质激素治疗,视力提高,为0.3～0.8.结论 CSC、孔源性视网膜脱离、原田病临床上各有其特有的典型体征,导致孔源性视网膜脱离、原田病误诊的主要原因为眼底病知识掌握不全面、忽略散瞳眼底检查.     

重视中心性浆液性脉络膜视网膜病变的鉴别诊断

中心性浆液性脉络膜视网膜病变（CSC）是眼科常见病,以黄斑区浆液性视网膜脱离为典型特征,但部分患者可存在弥漫性视网膜色素上皮病变、脉络膜新生血管形成、大泡性视网膜脱离、纤维素性渗出等不典型表现.由于不典型CSC的表现和症状与息肉状脉络膜血管病变（PCV）、可累及后极的炎症类疾病（如Vogt-小柳-原田综合征）等类似,一些其他全身及眼部疾病也可引起浆液性视网膜脱离及不典型CSC表现,临床上常造成误诊或漏诊,而上述不同疾病的治疗方法存在很大差别,因此,眼科医师应该充分了解CSC的表现特征,尤其是不典型表现,注意患者全身情况,包括糖皮质激素的使用,做到准确诊断,合适治疗.     

急性视网膜坏死综合征的治疗分析

目的分析急性视网膜坏死（acute retinal necrosis syndrome,ARNS）临床表现和相应的治疗。方法回顾性分析2002年3月至2007年5月在眼科中心收治的ARNS患者22例25眼,分析其临床特征、治疗及预后。结果发病年龄19岁～60岁,平均43.7岁。单眼19例,双眼3例,双眼间隔均为1个月,病程4天～12个月。22眼视力〈0.3,20眼有前部葡萄膜炎,所有眼有玻璃体炎,23眼出现中轴和周边视网膜黄白色渗出、血管白鞘或闭塞,9眼裂孔源性视网膜脱离,来院前14眼未确诊。确诊后静脉给予大剂量阿昔洛韦及适量激素,口服阿昔洛韦维持4周～6周,玻璃体切割术的15眼中13眼视网膜复位,跟踪性的视网膜黄白色渗出缘光凝10眼均未发生视网膜脱离。治疗后9眼视力提高,其中8眼低于0.05,13眼视力在0.05～0.3之间,4眼视力高于0.3。结论ARNS中青年多发,损害视力严重,发病初期不易确诊,大剂量阿昔洛韦和适量激素治疗、玻璃体切割能控制炎症、复位脱离的视网膜,跟踪性激光光凝可有效防止视网膜脱离及向后极发展。强调及时诊断,药物、手术及激光的综合治疗。     

中心性浆液性脉络膜视网膜病变OCT浆液性脱离区测量及其与视力的关系

目的 探讨频域相干光断层扫描（SD-OCT）在中心性浆液性脉络膜视网膜病变（CSC）中的应用并对CSC浆液性脱离区各项定量指标的测量结果与患者视力的关系进行分析。设计 回顾性病例系列。研究对象 2010年11月至2011年3月在华中科技大学同济医学院附属同济医院眼科就诊并确诊为CSC的患者34例（37眼）。方法 所有患者均应用Spectralis OCT进行检查,观察视网膜浆液性脱离区形态学特征并根据不同形态进行视力分析,进一步用黄斑地形图分析软件测量黄斑部1、3 、6 mm 9个分区视网膜厚度及体积,测量浆液性脱离区脱离的高度和脱离宽度,采用SPSS17.0软件对OCT检查指标与患者的视力进行相关性分析。主要指标 视网膜浆液性脱离区形态学特征;1、3、6 mm 9个分区视网膜厚度及体积;浆液性脱离区脱离的高度和脱离宽度;患者视力。结果 SD-OCT图像示,所有患眼中出现单纯神经上皮层脱离22眼,单纯视网膜色素上皮层脱离者0眼,视网膜神经上皮层合并色素上皮层脱离者13眼,未见脱离者2眼;患者视力与1 mm视网膜厚度和体积、浆液性脱离区高度、 浆液性脱离区宽度均显著相关（r值分别为-0.406、-0.405、-0.438、-0.389,P均<0.05）,与3 mm四个分区的视网膜厚度及鼻侧和颞侧的体积高度相关（与上方、鼻侧、下方、颞侧的厚度,与鼻侧、 颞侧的体积之间的r值分别为-0.481、-0.462、-0.332、-0.358、-0.461、-0.357,P均<0.05）,与6 mm鼻侧和上方视网膜厚度及体积有一定的相关性（r分别为 -0.428、-0.466、-0.429、-0.468,P均<0.01）,与3 mm的上方、下方体积及6 mm颞侧和下方视网膜厚度及体积相关性不大（P均>0.05）;单纯神经上皮层脱离组(0.50±0.26)与视网膜神经上皮层合并色素上皮层脱离组(0.48±0.15)视力比较无显著差异（P=0.759）。结论 SD-OCT不仅能对CSC患者进行无创伤性的检查、鉴别其视网膜组织形态改变,还可对其病变进行定量的追踪观察辅助疗效评价,对判断患者的视力预后及随访病情变化有一定的指导意义。     

试题与答案

1.下列哪项不符合糖皮质激素诱发中心性浆液性脉络膜视网膜病变的表现:A.在激素用药过程中出现视力下降或视物变形;B.前房、玻璃体有明显炎症加重;C.眼底检查见单个或几个局限性视网膜浅脱离或视网膜下黄白色渗出;D.荧光素眼底血管造影显示色素上皮渗漏。2.以下不属于Leber遗传性视神经病变急性期的眼部表现是:A.视盘旁毛细血管扩张,假性视盘水肿;     

中心性浆液性脉络膜视网膜病变危险因素研究进展

中心性浆液性脉络膜视网膜病变(central serous chorioretinopathy,CSC)是一种脉络膜视网膜疾病,可引起特发性的视网膜浆液性脱离,与视网膜外屏障（血-视网膜屏障）的缺损有关。CSC主要好发于男性,表现为视力下降和（或）视物变形、对比敏感度下降。其发病原因多种多样,本文就CSC危险因素进行综述。     

3D-OCT引导下多波长激光治疗CSCR的疗效观察

目的：观察3 D-OCT引导下多波长激光治疗中心性浆液性脉络膜视网膜病变（ central serous chorioretinopathy,CSCR）的疗效。方法：收集2010-07/2013-07在长春爱尔眼科医院的典型性中心性浆液性脉络膜视网膜病变患者23例23眼,利用3 D-OCT模式定位中心性浆液性脉络膜视网膜病变渗漏点行多波长激光光凝治疗。术后随访24wk,观察术后视力、黄斑区神经上皮层浆液性脱离高度。结果：中心性浆液性脉络膜视网膜病变患者23例23眼经3D-OCT引导下多波长激光治疗后随访24wk,治疗后视力与治疗前相比较,有统计学意义（P〈0.05）。治疗前后OCT黄斑区神经上皮层脱离高度比较,有统计学意义（ P〈0.05）,治疗后OCT黄斑区神经上皮层脱离高度明显下降,浆液明显吸收。23例23眼中心性浆液性脉络膜视网膜病变患者除1例失访者外均未见全身或眼局部不良反应的发生。结论：3 D-OCT引导下多波长激光治疗中心性浆液性脉络膜视网膜病变与FFA指导下激光治疗中心性浆液性脉络膜视网膜病变效果相当,有一定的临床应用价值。     

中心性浆液性脉络膜视网膜病变治疗方法的研究进展

中心性浆液性脉络膜视网膜病变( central serous chorioretinopathy,CSC)是中心视力损失的一项重要原因,它主要好发于中青年男性,以后极部浆液性神经上皮层脱离伴有视网膜色素上皮( retinal pigment epithelium,RPE)水平的渗漏为特征。大多数急性CSC患者会自发吸收,但是对于持续性神经上皮层脱离的慢性CSC患者可能会发展为进展性的视力下降。本文对近年来关于CSC治疗方法的研究进展作简要综述,主要从激光光凝、光动力学疗法( PDT)、玻璃体内抗血管内皮生长因子治疗、醛固酮受体拮抗剂四方面进行阐述。     

曲安奈德玻璃体腔注射治疗原田病浆液性视网膜脱离

目的 评价曲安奈德玻璃体腔注射治疗原田病浆液性视网膜脱离患者疗效.方法 对6例(12只眼)临床诊断为原田病浆液性视网膜脱离患者,给予玻璃体腔内注射曲安奈德4 mg,观察其视网膜脱离复位情况、视力、眼压、眼底及并发症.结果 12只眼中检眼镜下2周内11只眼视网膜脱离复位,占91.7%,3周内视网膜脱离全部复位.视力有不同程度提高,追踪观察1个月时平均视力与术前比较差异具有统计学显著性意义.眼前节葡萄膜炎症反应减轻或消失.除1只眼白内障加重外无其它并发症.结论 曲安奈德玻璃体腔注射能迅速促进原田病浆液性视网膜脱离复位,减轻眼前节葡萄膜炎症反应,提高视力,无明显全身副作用.     

Indocyanine green angiography and pathophysiology of multifocal posterior pigment epitheliopathy

PURPOSE: To clarify the pathophysiology of multifocal posterior pigment epitheliopathy (MPPE), or bullous retinal detachment (RD)-an unusual manifestation of central serous chorioretinopathy (CSC)-we evaluated indocyanine green (ICG) angiographic findings of patients with MPPE. METHODS: Indocyanine green angiography was performed on 45 eyes of 26 patients with MPPE in our clinic during a 4-year period and compared with clinical and fluorescein angiographic (FA) findings. RESULTS: Ophthalmoscopically, in the posterior pole there were multiple yellowish-white retinal exudations, associated with flat, serous RD and bullous RD in the lower periphery. Fluorescein angiography demonstrated multiple massive leakages from the choroid into the subretinal space. These leakage sites corresponded to the retinal exudations. Indocyanine green angiography showed hyperfluorescence in the posterior pole of the choroid. The hyperfluorescence was first seen in the middle phase and became prominent in the late phase. This finding seems to be due to extravasation from the choriocapillaris. After laser photocoagulation of the leakage sites seen on FA, the leakages stopped and the retinal exudations and RD were resolved. Indocyanine green angiography, however, revealed hyperfluorescence in the posterior pole that was seen in active stage. DISCUSSION AND CONCLUSION: These ICG angiographic findings for MPPE show that hyperpermeability of the choroidal vessels may be the primary causative lesion. This is followed by an intrastromal accumulation of the extravasated choroidal fluid, which may be subclinical. Involvement of the retinal pigment epithelium may be secondary, and then the disease becomes manifest with RD. In MPPE, a severe form of CSC, the retinal pigment epithelium is involved extensively and widely, and prognosis is unfavorable. We conclude that MPPE and CSC represent opposite ends of a common morbid spectrum.     

Surgical management of bilateral exudative retinal detachment associated with central serous chorioretinopathy

PURPOSE: To report a case of bilateral bullous exudative retinal detachment in central serous chorioretinopathy (CSC) which was attached by vitrectomy and internal drainage of the subretinal fluid. METHODS: A 47-year-old man affected by bilateral atypical CSC with a bullous retinal detachment with subretinal exudate. A fluorescein angiogram (FAG) showed multiple points of leakage and staining of subretinal fibrosis. A tentative diagnosis of Vogt-Koyanagi-Harada (VKH) syndrome was made and the patient was treated with systemic corticosteroids and immunosuppressive agents. However, the subretinal fluid was not absorbed. He was then treated with vitrectomy and internal drainage of subretinal fluid. RESULTS: The retina was attached successfully in both eyes. Visual acuity improved to 20/50 in his left eye but did not improve in the right eye due to subretinal fibrotic scarring and atropic changes on the macula. CONCLUSIONS: Our case suggests that the surgical management of bullous exudative retinal detachment is safe and necessary.     

Optical coherence tomography evaluation of detached macula from rhegmatogenous retinal detachment and central serous chorioretinopathy

PURPOSE: To compare structural changes using optical coherence tomography (OCT) and visual acuity (VA) loss in patients with shallow macula-off rhegmatogenous retinal detachment (RD) and central serous chorioretinopathy (CSC) involving the macula. DESIGN: Retrospective, comparative observational study. METHODS: Fifteen eyes with rhegmatogenous RD and 21 eyes with CSC with comparable height of macular detachment (< or = 550 microm) were evaluated retrospectively. All eyes were subjected to complete ophthalmologic examination, including OCT analysis, and were followed up until complete resolution of RD. RESULTS: The mean height +/- standard deviation at the fovea was 290 +/- 153 microm in rhegmatogenous RD and 310 +/- 141 microm in CSC. Although the duration of symptoms was longer in CSC than in rhegmatogenous RD (35.0 +/- 38.0 days vs 8.3 +/- 8.0 days), initial (0.25 vs 0.64 logarithm of the minimum angle of resolution [logMAR] units; P = .001) and final VA (0.09 vs 0.49 logMAR units; P < .001) were significantly better in CSC. OCT analysis of rhegmatogenous RD showed intraretinal cyst formation, intraretinal separation, and undulation of outer detached retina in 10 (67%), nine (60%), and six (40%) eyes, respectively. Eyes with two or more preoperative structural changes had poorer initial VA than eyes with none or one structural change. In comparison, none of the 21 CSC eyes showed any of these changes (P < .001). CONCLUSIONS: Compared with CSC, macula-involving rhegmatogenous RD resulted in more rapid visual loss, despite similar height of foveal detachment. Structural changes on OCT may be correlated with different levels of visual function in these two conditions.     

Central serous choroidopathy with bullous retinal detachment

Summary We report here a new type of secondary retinal detachment that has never been clearly defined. The characteristic features of the disease are: (1) prevalence in middle-aged males, (2) bilateral involvement, (3) frequent existence of prodromal lesions that over long periods resemble central serous retinopathy, (4) in the evolution stage, appearance of multiple yellowish white exudative flecks of one-half to one disc in diameter at or near the posterior pole of the fundus, (5) fluorescein studies revealing pronounced leakage of dye from the choroid into the subretinal space at the sites of exudates, (6) retinal detachment of various degrees with shifting subretinal fluid and without tears, (7) no evidence of intraocular inflammation, (8) no filling abnormalities seen in the choroidal fluorescence, (9) no response to medical therapy, including steroids and antibiotics, (10) photocoagulation to leakage sites leading to rapid resolution of retinal detachment; otherwise, spontaneous healing of detachment occurring within about 7–9 months, leaving fibroblastic macular scars and marked visual loss, and (11) no evidence of systemic findings that may be of etiologic significance. From this characteristic clinical picture, the idea of a new clinical entity must be considered. Our findings in 35 eyes from 18 Japanese patients are discussed.     

Serous retinal detachment in a patient with aplastic anemia associated with parvovirus B19 infection

Background We report a case of unilateral serous retinal detachment (RD) associated with parvovirus B19 infection. Case report A 28-year-old woman had a clinical history of autoimmune hemolytic anemia and pure red cell aplasia associated with parvovirus B19 infection. She demonstrated focal serous RD without retinal exudates. A focal cataract and anterior vitreous cells were also observed. Fluorescein angiography (FA) revealed accumulation of subretinal fluid, but no vascular leakage. After vitrectomy, the retina was re-attached and visual acuity returned to 20/20. IgM antibody to parvovirus and viral DNA were detected by polymerase chain reaction in the vitreous fluid obtained at surgery. Conclusion To our knowledge, this is the first reported case of the presence of anti-viral IgM and viral DNA in vitreous sample. Furthermore, the ocular findings in our patient are definitively different from previously reported cases of parvovirus-associated ocular disorders.     

Bullous variant of idiopathic central serous chorioretinopathy

BACKGROUND: Spontaneous bullous serous retinal detachment (RD) with subretinal exudation complicating idiopathic central serous chorioretinopathy (ICSC) is a rare and infrequently described clinical entity. Clinical observations are described on this variant form in 11 patients, the largest series reported to date. METHODS: 13 eyes of 11 Indian patients having this entity were followed up clinically and angiographically for 12-24 months (retrospective, longitudinal). None of the patients had any previous history of other diseases nor were they on any medications. Four eyes received laser treatment (group A); nine eyes were not treated (group B). RESULTS: All 11 patients were male, aged 23-49 years (median 37 years). The clinical and photographic records revealed subretinal exudation and inferior bullous serous RD complicating ICSC with evidence of large, single or multiple, leaking retinal pigment epithelial detachments (PEDs) in all the cases. In group A, resolution of serous RD occurred in 12 weeks (median) with a visual recovery of >/=20/30 in three out of four eyes while in group B resolution of serous retinal detachment was observed in 14 weeks (median) with eight out of nine eyes achieving a visual acuity of >/=20/30. Subretinal fibrosis developed in two eyes in group A and none of the eyes in group B. CONCLUSION: The disease is an exaggerated form of ICSC and can occur spontaneously without any history of corticosteroid therapy. Recognition of this atypical presentation is important to avoid inappropriate treatment. These observations suggest that with respect to the duration of the disease and the final visual outcome laser therapy offers no additional benefit over the natural course of this variant form of ICSC.     

相干光断层扫描与荧光素眼底血管造影在中心性浆液性脉络膜视网膜病变诊断中的对比观察

目的观察对比相干光断层扫描（OCT）和荧光素眼底血管造影（FFA）在中心性浆液性脉络膜视网膜病变（CSC）诊断中的特点。设计回顾性病例系列。研究对象临床诊断为CSC的58例（62眼）患者。方法对临床诊断为CSC且均行FFA及OCT检查的58例（62眼）患者的临床资料进行对比观察,分析其影像特征。随访中每月行OCT检查,每3个月行FFA检查,对比两种影像学检查观察疾病演变过程的特点。主要指标FFA及OCT影像学表现。结果58例（62眼）患者OCT检查中,60眼（96．8％）有神经上皮脱离,其中55眼（88．7％）FFA表现为荧光渗漏,且均在OCT神经上皮脱离范围内,另5眼未见异常荧光;5眼（8．1％）伴色素上皮脱离,而FFA未见特殊表现;2眼（3．2％）OCT仅见色素上皮脱离,其中1眼FFA见黄斑鼻侧透见荧光,另1眼无异常荧光。治疗后3个月,OCT检查62眼中16眼（24．2％）见神经上皮脱离,16眼中FFA仅5眼（8．1％）有荧光渗漏;2眼伴色素上皮脱离,而FFA未有特殊表现。对FFA检查及随诊中发现渗漏点在中心凹500μm外者（57眼）行激光光凝治疗。结论OCT和FFA在对CSC的诊断上各具优势,OCT可观察到视网膜病变的形态改变,FFA可定位血管渗漏,利于激光治疗。两者结合是CSC最有效的影像诊断技术。     

Submacular exudates with serous retinal detachment caused by cat scratch disease

Purpose: To present submacular exudates as a manifestation of cat scratch disease. Methods: Report of two cases. Results: The first patient, a 34-year-old man, developed submacular exudates with serous retinal detachment ten days after having axillary lymphadenopathy and fever. The second patient, a 30-year-old woman, developed submacular exudates with serous retinal detachment mimicking central serous chorioretinopathy. Fluorescein angiography revealed late staining of the subretinal lesions in both cases.The lesion resolved spontaneously in the first patient, while sulfamethoxazole and trimethoprim was required for the second patient. Both patients had a positive IgG titer for Bartonella henselae. Conclusions: Submacular exudates with serous retinal detachment can occur in cat scratch disease. Cat scratch disease should be included in the differential diagnosis of submacular exudates with central serous chorioretinopathy.