玻璃体切除治疗视网膜分支静脉阻塞引起玻璃体积血的临床效果

目的:探讨玻璃体切除手术治疗视网膜分支静脉阻塞引起的玻璃体积血的临床效果。方法:回顾分析28例28眼视网膜分支静脉阻塞引起的玻璃体积血患者进行闭合式玻璃体切除,联合增殖膜剥离、眼内激光光凝及玻璃体腔长效气体、硅油或灌注液填充手术的临床疗效。结果:该28例患者术中均可见视网膜分支静脉阻塞闭锁呈白线状。视网膜静脉阻塞颞上方20例,颞下方8例。合并视盘新生血管2例,18例阻塞区可见视网膜新生血管及交通支。并发视网膜脱离7例,患者术前及术后视力比较有统计学差异(P<0.05)。结论:玻璃体切除是视网膜分支阻塞的有效手术方法,术中应谨慎去除阻塞区增殖病灶,光凝视网膜无灌注区,术后注意观察阻塞部位的视网膜复位及增殖情况。     

Characteristics of the Hemispheric Retinal Vein Occlusion

Hemispheric retinal vein occlusions involve the venous return from approximately one-half of the retina and have characteristics of both central retinal vein occlusions and branch retinal vein occlusions. One hundred six such occlusions were studied in 104 patients whose average age was 66 years. The site of the hemispheric vein occlusion was located in a branch retinal vein in 90% of the eyes, and in 10% of the eyes it was located in one of the dual intraneural trunks of the central retinal vein. Of these eyes, 11 developed neovascularization of the disc, 9% developed neovascularization of the retina elsewhere, 9% developed neovascularization of the iris, and 3% developed neovascular glaucoma. Neovascularization was positively correlated with an increasing percentage of capillary nonperfusion (ischemic index) within the area of occlusion. Prophylactic argon laser treatment was effective in reducing the incidence of neovascularization in eyes with significant capillary nonperfusion.     

激光诱发视网膜静脉阻塞侧支循环的实验研究

目的 探讨在兔眼视网膜分支静脉阻塞（branch retinal vein occlusion,BRVO)模型基础上,利用激光诱发、建立视网膜和脉络膜静脉吻合的可行性及安全性。方法 通过光动力法建立21只兔（42只眼）BRVO模型,利用激光诱发并形成视网膜和脉络膜静脉吻合;对侧无BRVO眼作为对照,同样用激光击射,诱发吻合支形成。结果 在建立BRVO模型的21只眼中,4只眼形成了视网膜和脉络膜静脉吻合,形成时间为3－5周。对照眼中,1只眼形成了视网膜和脉络膜静脉吻合,形成时间为5周。在观察2－5个月期间,由激光击射引起的脉络膜、视网膜或玻璃本出血均在3周内吸收,未见其它严重并发症。结论 利用激光诱发并形成视网膜和脉络膜静脉吻合,在技术上可行,较为安全,但在提高成功率方面尚有待进一步研究 。     

Photocoagulation in Eales' disease

Between 1970 and 1991 the authors examined 466 cases with Eales' disease. 359 eyes of 295 of these 466 cases received photocoagulation treatment. The mean age was 30.4, ranging between 14 and 55 years. Ten eyes with persistent vitreous hemorrhage underwent pars plana vitrectomy before photocoagulation. 210 eyes were treated with xenon arc, 135 with argon laser, 12 with krypton laser and two with yellow dye laser. Hypoxic areas and retinal neovascularizations were closed completely in 298 eyes. In 21 eyes with elevated neovascularizations intruding into the vitreous cavity feeder vessel photocoagulation was used. 24 eyes with disc neovascularization were treated with panretinal photocoagulation. 12 eyes with branch vein occlusion and four eyes with central vein occlusion received photocoagulation treatment to areas of non-perfusion and retinal neovascularization. At a mean follow-up of 43 months, seven new retinal neovascularizations and three new disc neovascularizations developed in eyes which previously had received photocoagulation for retinal neovascularization and hypoxia. Nine out of 21 eyes with elevated neovascularizations developed vitreous hemorrhage. Disc neovascularization resolved completely in 13 out of 24 eyes, it partially regressed in eight eyes and did not respond to treatment in three eyes. The visual acuities were improved in 12.3%, maintained in 77.4% and deteriorated in 10.3% of the eyes after treatment. Periodic follow-up and early photocoagulation treatment is useful in stabilizing the retinal lesions and in maintaining functional levels of vision in Eales' disease.     

Photocoagulation in Eales' disease

Between 1970 and 1991 the authors examined 466 cases with Eales' disease. 359 eyes of 295 of these 466 cases received photocoagulation treatment. The mean age was 30.4, ranging between 14 and 55 years. Ten eyes with persistent vitreous hemorrhage underwent pars plana vitrectomy before photocoagulation. 210 eyes were treated with xenon arc, 135 with argon laser, 12 with krypton laser and two with yellow dye laser. Hypoxic areas and retinal neovascularizations were closed completely in 298 eyes. In 21 eyes with elevated neovascularizations intruding into the vitreous cavity feeder vessel photocoagulation was used. 24 eyes with disc neovascularization were treated with panretinal photocoagulation. 12 eyes with branch vein occlusion and four eyes with central vein occlusion received photocoagulation treatment to areas of non-perfusion and retinal neovascularization. At a mean follow-up of 43 months, seven new retinal neovascularizations and three new disc neovascularizations developed in eyes which previously had received photocoagulation for retinal neovascularization and hypoxia. Nine out of 21 eyes with elevated neovascularizations developed vitreous hemorrhage. Disc neovascularization resolved completely in 13 out of 24 eyes, it partially regressed in eight eyes and did not respond to treatment in three eyes. The visual acuities were improved in 12.3%, maintained in 77.4% and deteriorated in 10.3% of the eyes after treatment. Periodic follow-up and early photocoagulation treatment is useful in stabilizing the retinal lesions and in maintaining functional levels of vision in Eales' disease.     

Management of retinal vein occlusion

Recent research into the relationship between retinal venous occlusion and general vascular disorders has shown that retinal venous occlusion seems to be related only to systemic hypertension. The role of systemic hemorrheologic parameters in the pathophysiology of venous occlusion is a controversial one. Of the various treatment modalities, isovolemic hemodilution has been found to improve retinal perfusion, but the treatment must be repeated about once a week for at least 2 months. The presence of tissue hypoxia in areas of ischemic venous occlusion has been confirmed by measurements of preretinal oxygen pressure in experimental venous occlusion. Reduced preretinal oxygen pressure in these experimental cases normalized after retinal scatter photocoagulation. The inhibiting role of posterior vitreous detachment on posterior segment neovascularization and the fact that panretinal photocoagulation has a better effect on anterior than on posterior segment neovascularization have been evaluated in clinical studies.     

Induced chorioretinal venous anastomosis in experimental retinal branch vein occlusion.

Iatrogenic retinal vein to choroidal vein anastomoses were created using laser photocoagulation in six of seven dog eyes in which a partial branch retinal vein occlusion had previously been created photochemically. A similar attempt to create an anastomosis was made in six control eyes in which no branch vein occlusion was present. In the eyes in which a branch retinal vein had been created, a venous chorioretinal anastomosis appeared to be present by 3 to 6 weeks. In three control eyes similar venous anastomosis was created; however this took 6 to 8 weeks to develop and was of much smaller calibre than the one that developed in the presence of a partial branch retinal vein occlusion. No adverse complications were noted in the period of the study (3 months). This study demonstrates that chorioretinal venous anastomoses can be created and may be of use in the treatment of partial retinal vein occlusions that show signs of progression.     

A laser coagulation technic in central retinal vein occlusion

The authors analyze the method of laser therapy in venous retinal occlusions. In view of the different therapeutic approach in occlusion of the branch and the trunk of the retinal vein, the paper has two parts. In occlusion of the branch of the retinal vein the authors describe the applied techniques of laser photocoagulation recommended by L'Esperance--quadrant barrage, barrier of the macula and arteriolar constriction. Technical data on photocoagulation are presented. In the treatment of occlusions of the trunk of the retinal vein the authors use panretinal photocoagulation, however, only in the ischaemic form of occlusion as a prevention of neovascular glaucoma. The authors mention some of their own experience with the treatment of venous occlusions of the retina by argon laser photocoagulation and they present their own therapeutic schedule.     

Retinal vascular occlusion in patients infected with human immunodeficiency virus

PURPOSE: To describe the clinical features of retinal vascular occlusions (macrovasculopathy) and the proportion of affected patients with human immunodeficiency virus (HIV) infection. METHODS: Retrospective chart review of all HIV-infected individuals with retinal vascular occlusions seen at a single tertiary care clinic between November 1983 and May 1998. RESULTS: Retinal vascular occlusion was found in 38 eyes of 33 (1.3%) of the 2,484 consecutive patients examined. Of the 33 patients, 16 (48.5%) had central retinal vein occlusion, 9 (27.3%) had branch retinal vein occlusion, 4 (12.1%) had hemiretinal vein occlusion, and 1 each (3.0%) had central retinal arterial occlusion, branch retinal arterial occlusion, and combined hemiretinal vein occlusion and branch retinal artery occlusion. One patient (3.0%) had Purtscher-like retinopathy in one eye. Multiple regression analysis revealed that macrovasculopathy was associated with the presence of noninfectious retinal microvasculopathy (odds ratio, 5.76; 95% confidence interval, 2.59-12.80). Vision at the time of diagnosis ranged between 20/20 and no light perception. Twenty-five (75.8%) of the 33 patients had follow-up examinations for a mean period of 9.1 months. Ocular findings during follow-up included capillary dropout in 3 patients (11.5%), posterior pole neovascularization in 4 (15.4%), vitreous hemorrhage in 4 (15.4%), and optic atrophy in 6 (23.1%). Vision at the last eye examination ranged between 20/20 and no light perception and was 20/200 or worse in 15 (39.5%) of 38 eyes. CONCLUSIONS: Patients with HIV infection have a small risk of retinal vascular occlusion, but complications and visual loss are common in affected patients. There is a strong association between noninfectious retinal microvasculopathy and retinal vein occlusions.     

Problems with attempted chorioretinal venous anastomosis by laser for nonischemic CRVO and BRVO

PURPOSE: To report the complications and long-term results of laser-induced chorioretinal venous anastomosis in vein occlusions. PATIENTS AND METHODS: Eight consecutive eyes, 3 with central retinal vein (CRVO) and 5 with branch retinal vein occlusion (BRVO), were observed for up to 5 years after attempted laser-induced chorioretinal venous anastomosis. Results: Successful chorioretinal venous anastomoses were created in 2 (25%) eyes. Patients had severe complications, including vitreous hemorrhage, choroidal neovascular membrane, choriovitreal neovascularization, rubeosis iridis and neovascular glaucoma. CONCLUSION: The utilization of a chorioretinal venous anastomosis by laser with proposed laser settings as a therapeutic modality should be further analyzed, and a careful long-term follow-up must be done to avoid vision-threatening complications.     

Late complications in branch retinal vein occlusion

Neovascularization in branch retinal vein occlusion usually develops 6–12 months after the onset of the disease, although some cases have been reported in which neovascularization and subsequent vitreous haemorrhage developed 2–3 years later.This is a report of nine cases of late appearance of vitreous haemorrhage due to branch retinal vein occlusion, which occurred 3–6 years after the initial onset of the disease. In two of these nine cases the vitreous haemorrhage was very profound and had to be managed by vitrectomy. We have studied the remaining seven cases, which had retinal ischaemia and optic disc or retinal neovascularization documented by fluorescein angiographic examination. Laser coagulation was applied in these seven cases, which resulted in considerable regression of the neovascularization and absorption of the vitreous haemorrhage. In one out of the seven cases recurrent vitreous haemorrhages appeared and it was finally treated by vitrectomy. Visual acuity improved in six of the seven cases. The follow-up period ranged from 12 to 48 months.The late appearance of the ischaemic type of branch retinal vein occlusion with neovascularization can be attributed to the change in character of the initially mild oedematous form of the disease. Partial posterior vitreous detachment and traction exerted at some later stage upon the neovascularization could be additional factors of the late appearance of vitreous haemorrhage.Patients with branch retinal vein occlusion should be followed up regularly over a long period of time in order to avoid late complications of the disease, such as vitreous haemorrhage following optic disc or retinal neovascularization.     

倍频Nd:YAG激光治疗视网膜静脉阻塞的新生血管

目的探讨倍频Nd:YAG532激光光凝治疗视网膜静脉阻塞新生血管的方法和疗效。方法对26例视网膜静脉阻塞伴新生血管的31眼采用倍频Nd:YAG532激光进行视网膜光凝治疗。光凝后经3月～2.5a随访,对比分析光凝前后的视力变化及眼底改变。结果有效21眼(68％),好转7眼(22％),无效3眼(10％)。视力提高19眼(61％)。结论倍频Nd:YAG532激光光凝术对视网膜静脉阻塞新生血管的消退及预防玻璃体积血具有显著疗效。     

Clinical and angiographic features in nasal branch retinal vein occlusion

PURPOSE: To analyse the epidemiological and clinical characteristics of nasal branch retinal vein occlusion (NBRVO). METHODS: Patients affected by branch retinal vein occlusion observed in the out-patient departments of the Eye Clinic of Trieste between January 1995 and January 1999 were enrolled. RESULTS: Out of 144 patients with branch retinal vein occlusion, 128 (88.9%) were affected by temporal branch retinal vein occlusion (TBRVO), and 16 patients were affected by NBRVO (11.1%). The two groups did not differ as far as systemic hypertension, diabetes mellitus, glaucoma and ischaemic heart disease were regarded. NBRVO cases were characterized by better visual acuity and greater figures of capillary non-perfusion, retinal neovascularization and vitreous haemorrhage. CONCLUSIONS: NBRVO, even though infrequent, shares the same epidemiological characteristics as TBRVO. The higher prevalence of ischaemic cases in the NBRVO group could depend on a bias during the enrolment of patients, because especially symptomatic patients may have been examined in our out-patient departments. The relatively high percentage of epiretinal membrane formation after laser photocoagulation suggests particular caution, especially in cases presenting with vitreous haemorrhage.     

Role of the vitreous in retinal neovascularization evaluated by a comparison of central retinal vein occlusion and branch retinal vein occlusion

Thirty three patients (33 eyes) with central retinal vein occlusion (CRVO) and 80 patients (81 eyes) with branch retinal vein occlusion (BRVO) were studied in an attempt to investigate the role of the vitreous in the formation of retinal neovascularization. All these eyes had some areas of capillary nonperfusion confirmed by fluorescein angiography and no scatter photocoagulation before the first examination. The incidence of new vessels at the optic disc (NVD) in CRVO was not significantly different from that in BRVO. However, the incidence of new vessels elsewhere (NVE) in CRVO was significantly less than that in BRVO. Follow-up vitreous examination of 36 cases while they had not developed NVD and/or NVE showed a higher incidence of posterior vitreous detachment from the mid-peripheral retina (MP-PVD) in CRVO than in BRVO. On the other hand, there was no statistically significant difference in the incidence of posterior vitreous detachment from the optic disk (D-PVD) between CRVO and BRVO. The high incidence of MP-PVD in CRVO may explain the low incidence of NVE in CRVO.     

Branch retinal vein occlusion: clinical findings, natural history, and management

Branch retinal vein occlusion is a common retinal vascular condition characterized by sectoral intraretinal hemorrhages, retinal ischemia, retinal exudates, and macular edema. The site of occlusion usually occurs in the vicinity of arteriovenous crossing sites, and is predisposed by various systemic and local factors. Complications of branch retinal vein occlusion include macular edema, capillary nonperfusion, retinal neovascularization, vitreous hemorrhage, and tractional retinal detachments that often result in loss of vision. Until recently, laser photocoagulation was the only therapy recommended for eyes with branch retinal vein occlusion. New medical and surgical treatment options aimed at reducing macular edema have been evaluated in recent years, and include intraocular injections of steroids and anti-vascular endothelial growth factor agents, sustained drug release devices, vitrectomy, and sheathotomy.     

Treatment of neovascularization secondary to branch retinal vein obstruction

Fifty patients who developed preretinal or papillary neovascularization following tributary vein occlusion were treated by laser photocoagulation. Areas of non-perfused retina within the distribution of the obstructed vein were identified by fluorescein angiography and ablated using moderately intense laser photocoagulation burns. In forty-six patients there was satisfactory atrophy of both prerentinal and papillary neovascularization without further complication or vitreous haemorrhage. Four patients who responded poorly to laser photocoagulation did so either because areas of ischaemic retina were inadequately treated or because they were unamenable to laser photocoagulation e.g., sited in the parafoveal region. Ablation of ischaemic perimacular retina together with associated intraretinal microvascular abnormalities aided the resolution of macular oedema in 19 patients. No post-operative complications could be attributed to laser photocoagulation excepting the development of fine perimacular retinal folds in one patient.     

增生型糖尿病视网膜病变玻璃体切除手术后再出血病因及治疗

目的 分析增生型糖尿病视网膜病变(PDR)玻璃体切割手术后再出血病因，观察再治疗效果。 方法 回顾分析302例PDR患者315只患眼接受玻璃体切割手术治疗后32只眼再出血并再次治疗后随访3~48个月（平均随访时间12个月）的临床资料。 结果 PDR玻璃体切割手术后再出血发生率为10%，再出血发生时间为手术后1～210 d，平均时间为51 d。再出血的主要原因中，28%为巩膜切口纤维血管向内生长，19%为视盘表面残存新生血管膜或血管残端处理不当，22%为视网膜激光光凝不足，9%为视网膜表面新生血管膜剥除不彻底，6%为视网膜静脉阻塞，16%为外力作用。通过冷凝巩膜切口处纤维血管、剥离视盘和视网膜表面残存新生血管膜并电凝视盘表面血管残端、补充视网膜激光光凝、 包扎双眼等治疗，再出血眼视力提高者占91%，视力下降者占9%。再次手术后并发症主要包括再次出血、虹膜后粘连、晶状体混浊加重、角膜上皮愈合延迟等。 结论 PDR玻璃体切割手术治疗后再出血的主要原因是巩膜切口纤维血管向内生长、视盘表面和（或）视网膜表面新生血管膜剥除不彻底、血管残端处理不当、视网膜激光光凝不足和外力作用。处理好巩膜切口、彻底剥离视盘和视网膜表面新生血管膜、电凝血管残端以及足够的视网膜激光光凝是预防和治疗PDR玻璃体切割手术后再出血的有效方法。(中华眼底病杂志,2007,23:238-240)      

氪激光治疗视网膜静脉阻塞的新生血管

目的探讨氪激光治疗视网膜静脉阻塞新生血管的方法和疗效 。方法对27例视网膜静脉阻塞伴有新生血管的28只患 眼采用氪绿、氪红激光进行光凝治疗。光凝后经6个月～2．５年随访,对比分析光凝前后的 荧光素眼底血管造影及视力变化情况。结果新生血管 萎缩20只眼,占71.4％,好转6只眼,占21.4%,无效2只眼,占7.2%。 视力进步17只眼,占60.7%。结论氪激光光凝术对视网膜静脉阻塞新生血管的消退及预防其玻璃体积血具有显著疗效。(中华眼底病杂志,2001,17:12-14)     

Prevalent misconceptions about acute retinal vascular occlusive disorders

Acute retinal vascular occlusive disorders collectively constitute one of the major causes of blindness or seriously impaired vision, and yet there is marked controversy on their pathogeneses, clinical features and particularly their management. This is because the subject is plagued by multiple misconceptions. These include that: (i) various acute retinal vascular occlusions represent a single disease; (ii) estimation of visual acuity alone provides all the information necessary to evaluate visual function; (iii) retinal venous occlusions are a single clinical entity; (iv) retinal vein occlusion is essentially a disease of the elderly and is not seen in the young; (v) central retinal vein occlusion (CRVO) is one disease; (vi) fluorescein fundus angiography is the best test to differentiate ischemic from nonischemic CRVO; (vii) the site of occlusion in CRVO is invariably at the lamina cribrosa; (viii) clinical picture of CRVO is often due to compression or strangulation of the central retinal vein (CRV) in the lamina cribrosa and not its occlusion; (ix) an eye can develop both CRVO and central retinal artery occlusion (CRAO) simultaneously; (x) every eye with CRVO is at risk of developing neovascular glaucoma; (xi) lowering intraocular pressure (IOP) helps to improve retinal circulation in an eye with CRVO; (xii) every patient with retinal vein occlusion should have complete hematologic and coagulation evaluation; (xiii) the natural history of CRVO does not usually involve spontaneous visual improvement; (xiv) management of CRVO is similar to that of venous thrombosis anywhere else in the body, i.e. with aspirin and/or anti-coagulants; (xv) fibrinolytic agents can dissolve an organized thrombus in the CRV; (xvi) it is beneficial to lower blood pressure in patients with CRVO; (xvii) panretinal photocoagulation used in ischemic retinal venous occlusive disorders has no deleterious side-effects; (xviii) glaucoma or ocular hypertension can cause branch retinal vein occlusion; (xix) branch retinal vein occlusion can cause neovascular glaucoma; (xx) in eyes with CRAO, the artery is usually not completely occluded; (xxi) CRAO is always either embolic or thrombotic in origin; (xxii) amaurosis fugax is always due to retinal ischemia secondary to transient retinal arterial embolism; (xxiii) asymptomatic plaque(s) in retinal arteries do not require a detailed evaluation; (xxiv) retinal function can improve even when acute retinal ischemia due to CRAO has lasted for 20h or more; (xxv) CRAO, like ischemic CRVO, can result in development of ocular neovascularization; (xxvi) panretinal photocoagulation is needed for "disc neovascularization" in CRAO; (xxvii) fibrinolytic agents are the treatment of choice in CRAO; (xxviii) there is no chance of an eye with retinal arterial occlusion having spontaneous visual improvement; (xxix) absence of any abnormality on Doppler evaluation of the carotid artery or echography of the heart always rules out those sites as the source of embolism; and (xxx) absence of an embolus in the retinal artery means the occlusion was not caused by an embolus. The major cause of all these misconceptions is the lack of a proper understanding of basic scientific facts related to the various diseases. The objective of this paper is to discuss these misconceptions, based on these scientific facts, to clarify the understanding of these blinding disorders, and to place their management on a rational, scientific basis.     

Anatomy of arteriovenous crossings in branch retinal vein occlusion

We studied the photographic records of 292 eyes, including 103 eyes with branch retinal vein occlusion, 90 fellow eyes, and 99 control eyes without branch retinal vein occlusion. All arteriovenous crossings within three disk diameters of the optic disk, including the crossings at the sites of branch retinal vein occlusions, were studied. The relative positions of the crossing artery and vein could be determined at 1,939 crossings in all eyes. Crossings at which a vein crossed over an artery were a common finding (22.3% to 33.0% of crossings), but were rare at the crossings where branch retinal vein occlusions were found (2.4%). A greater proportion of arterial overcrossings was found in eyes with branch retinal vein occlusions (77.7%) compared to fellow eyes (70.6%) or control eyes (67.0%). Our data indicate that arterial overcrossings are at relatively higher risk of branch retinal vein occlusion than venous overcrossings, and that the risk of branch vein occlusion in an eye is proportional to the number of arterial overcrossings in the eye.