玻璃体黄斑中心凹牵拉的光学相干断层扫描分析

目的 :应用光学相干断层扫描 (opticalcoherencetomography ,OCT)定量分析玻璃体牵拉与黄斑裂孔形成的关系。探讨OCT检查对诊断特发性黄斑裂孔的意义。方法 :OCT显示为玻璃体黄斑中心凹牵拉的 18例 ( 2 0眼 )患者进行随访。垂直和水平线性OCT经过黄斑中心凹 ,分析OCT图像 ,测量黄斑厚度及玻璃体后脱离 ,定量分析黄斑裂孔与玻璃体牵拉的关系。结果 :平均年龄为 63 2± 8 4岁 ( 5 0～ 77岁 ) ,男性 2例 ,女性 16例。临床诊断为临界黄斑裂孔 9眼 ,黄斑囊肿 2眼 ,玻璃体黄斑牵拉 3眼 ,黄斑囊样水肿 3眼 ,视网膜前膜 1眼及诊断不详 2眼。首次OCT图像显示玻璃体后皮质粘连在黄斑中心凹处 ,中心凹变平或隆起 ,神经上皮间呈低反射的囊肿。未形成裂孔眼的玻璃体后脱离逐渐增加 ,中心凹的隆起度亦随之增加。随访视力显著下降 (P =0 0 0 1,配对T检验 ) ;视力与黄斑的隆起度呈负相关 (r2 =0 5 3 ,P =0 0 0 3 ,Pearson相关分析 )。 2 0眼中 8眼 ( 4 0 % )形成黄斑裂孔 ,板层裂孔 1眼 ,Ⅱ期裂孔 5眼 ,Ⅲ期裂孔 2眼。裂孔形成组与未形成组的视力、黄斑厚度及玻璃体后脱离的差异不显著 (P >0 0 5 )。结论 :OCT对分析、诊断、监测玻璃体黄斑牵拉具有非常有意义的临床价值。玻璃体黄斑中心凹牵拉是裂孔形成的原因之一     

玻璃体手术治疗玻璃体黄斑牵引综合征

目的:探讨玻璃体手术治疗玻璃体黄斑牵引综合征疗效。方法:手术前后经光学相干断层扫描(optical co-herence tomography, OCT)、多焦视网膜电图(multifocal electroretinography,m ERG)、荧光素眼底血管造影(funds fluorescein angiography,FFA)等检查确诊为玻璃体黄斑牵引综合征患者12例12眼。采用标准三切口玻璃体切除手术。切除已脱离玻璃体后皮质,松解玻璃体视网膜牵引。结果:黄斑部牵引解除12眼,视力提高2行以上9眼。手术后未见明显并发症。结论:玻璃体手术是治疗玻璃体黄斑牵引综合征的有效方法。     

中心凹型糖尿病性黄斑水肿研究进展

糖尿病性黄斑水肿(DME)的特征是渗出液在黄斑积聚,是糖尿病患者最常见的威胁视力的视网膜疾病.其中,中心凹型DME是糖尿病患者视力丧失的主要原因,但对中心凹型DME的认识,尤其是病理生理机制及治疗方案的选择仍有进一步探讨的必要.目前,国内有关中心凹型DME的相关报道较少,对该病有一个完整的认识可以提高临床工作者对此病的...     

中心凹周玻璃体脱离是原发性黄斑裂孔形成的主要病因

目的：评价在有早期原发性黄斑裂孔形成的眼内后玻璃体皮质与后部视网膜之间的关系。方法：对患有一期或二期原发黄斑裂孔的26例连续患者的26只眼,进行全部眼科检查、接触镜生物显微镜检查和B超检查或玻璃体视网膜手术或二者都施行。在曾施行手术眼中,于导致后玻璃体脱离之前,用一尖端为硅的套管细心地检查后玻璃体皮质层。结果：26只眼中的25只眼（96％）,经一种或多种检查技术显示中心凹周玻璃体局限性浅脱离,典型地延伸至血管弓水平。在这25只眼中,后玻璃体膜分离在4只眼中（16％）可用生物显微镜查见;在23只眼（100％）于手术中查见。有一期孔的6只眼中全部及有二期孔而无盖的13只眼中12只眼（92％）,在中心凹明显可见持久性玻璃体粘连。结论：这些所见提示,局限性中心凹周玻璃体脱离（年龄相关性后玻璃体脱离的早期）是原发性黄斑裂孔形成的主要致病事件。我们假定后玻璃体从中心周视网膜的脱离,由于对中心凹施加前牵拉以及将伴发眼球转动的有力玻璃体牵拉局限到中心凹,导致中心凹裂开。     

玻璃体黄斑牵引综合征

一、基本概念玻璃体黄斑牵引综合征 (vitreomacular tractionsyndrome,VTS)是指玻璃体不完全后脱离引起的玻璃体对黄斑的持续牵引〔1〕。过去由于认识所限 ,常把这一临床情况视为黄斑裂孔前期或特发性黄斑皱褶。但近年来 ,随着检查手段和玻璃体手术的进步 ,发现它有着不同于前两种疾病的明显特点 ,所以 Smiddy等将 VTS看作一种独立疾病类型〔2～ 4〕,其最主要的特征为眼底黄斑区存在持续地前后向牵引 ,这种牵引是由特征性的玻璃体不完全后脱离引起的 ,因为玻璃体不完全后脱离保持以中心凹为中心 1～ 6PD左右的玻璃体与视网膜粘伏 ,周围…     

板层黄斑裂孔与正常中心凹厚度的黄斑假洞的比较

目的比较与视网膜前膜(ERM)相关的黄斑板层裂孔(ILH)和具有正常中心凹厚度的黄斑假洞(MPH),在定量和形态学上的差异。方法27眼(25例)具有黄斑洞或黄斑假洞(MPH)的临床形态的黄斑前膜患者,应用视网膜光学相干断层扫描(OCT)评价其中心凹厚度与形态。当每个患者至少两次不同的扫描结果显示中心凹厚度≥135μm时,可诊断为MPH;当厚度介于0与135μm之间时,可诊断为ILH。而能够影响数据的中心凹厚度>202μm的MPH、全层黄斑裂孔及黄斑部玻璃体牵拉及其他黄斑病变的患者,则被排除出本试验。结果6例6眼(22.2%),年龄56±18岁被诊断为ILHs,4例4眼(14.4%),年龄70±9岁被诊断为正常厚度的黄斑假洞。ILH与NT-MPHs的最小中心凹厚度范围分别为74～108(平均87±12.6)μm,135～191(平均166±27)μm。所有NT-MPHs和其中4例ILH患者,被发现具有囊样变。其他17眼,厚度都>203μm,具有更加明显的中心凹囊样变。结论OCT的定量检测能够鉴别ILHs与NT-MPHs。囊样变的ILH能够增厚变为MPHs,定量和随访重复测量的结果能够有助于确定囊样变ERMs的手术时机和手术适应症。     

23G玻璃体切除术治疗视网膜静脉阻塞黄斑水肿合并玻璃体黄斑牵拉或黄斑前膜

目的:探讨23G玻璃体手术治疗视网膜静脉阻塞黄斑水肿合并玻璃体黄斑牵拉或视网膜黄斑前膜的临床疗效.方法:对22例22眼视网膜静脉阻塞黄斑水肿合并玻璃体黄斑牵拉或黄斑前膜病例进行回顾性分析.其中12例12眼行23G玻璃体切除手术并剥离视网膜前膜和/或内界膜作为观察组即手术组;另外10例10眼未行手术患者作为对照组,并收集全部患者治疗前、治疗后1、3、6mo的最佳矫正视力(BCVA)及中央视网膜厚度(CRT)资料进行统计学分析.结果:观察组和对照组治疗前BCVA和CRT差异无统计学意义(P=0.645、0.206).观察组术后各随访时间点BCVA较术前均明显提高,差异有统计学意义(F=2.895,P=0.048);CRT较术前明显降低,差异均有统计学意义(F=16.431,P<0.01).对照组随访期内1、3、6mo BCVA及CRT较治疗前无明显改善,差异均无统计学意义.随访期3、6mo时,观察组BCVA较对照组提高,CRT较对照组时降低,差异均有统计学意义(P<0.05);而1mo时,观察组BCVA及CRT较对照组无明显改善.结论:23G玻璃体切割手术可以有效地提高视网膜静脉阻塞黄斑水肿合并玻璃体黄斑牵拉或黄斑前膜患者视力并降低中央视网膜厚度.     

Chronic macular edema associated with extrafoveal vitreoretinal traction

AIM: To describe an association between extrafoveal vitreoretinal traction and chronic macular edema, either diffuse (DiME) or cystoid (CME), by the use of optical coherence tomography (OCT). METHODS: Charts and OCT findings of two patients with persistent DiME or persistent DiME accompanied by CME, both associated with extrafoveal vitreous traction membranes were analyzed. Excluded were eyes that either had another vitreoretinopathy that could affect the analysis, had undergone pars plana vitrectomy or that had been treated by intravitreal medications. An age-matched normal control group for OCT (n=12) allowed for the quantification of the normal macular thicknesses. RESULTS: One patient (one eye) following perforating ocular injury and one patient (one eye) of idiopathic origin, both with chronic macular edema refractive to conventional treatment, were found to be associated with extrafoveal vitreoretinal traction in each eye. Retinal edema that was underlying the traction site in each eye was in continuum with the central macular edema, thus manifesting as diffuse macular edema. The automatic central 6-radial lines program in the OCT enabled the detection of the traction site in one eye, while in the other eye the diagnosis was achieved only with the additional use of the Line group program. CONCLUSION: Chronic diffuse macular edema might be related to extrafoveal vitreoretinal traction. Careful search with the diverse OCT programs should be made in order to detect extrafoveal traction sites. Further studies and a larger cohort are required to compare the efficacy of early vitrectomy or pharmacologic vitreolysis versus the current therapeutic approaches in these situations.     

Macular traction detachment and diabetic macular edema associated with posterior hyaloidal traction

PURPOSE: To review the clinical, photographic, fluorescein angiographic, and optical coherence tomographic findings in patients with the diabetic macular traction and edema (DMTE) associated with posterior hyaloidal traction (PHT). METHODS: We performed a prospective review of nine eyes of nine patients with diabetic macular edema (DME) and PHT on clinical examination. The patients had a comprehensive ophthalmic history and examination, color photographs, fluorescein angiography, and optical coherence tomography (OCT). RESULTS: All patients had diabetic retinopathy and DME. Of the nine eyes, eight patients had previous focal or grid photocoagulation. All nine eyes had a thickened, taut, glistening posterior hyaloid on clinical biomicroscopic examination with no posterior vitreous separation. Fluorescein angiography was performed on seven eyes, and all had early hyperfluorescence with deep, diffuse, late leakage in the macular area consistent with DMTE associated with PHT. Optical coherence tomography scans of the macular region revealed retinal thickening in all eyes with a mean retinal thickness of 556.9 +/- 114.7 microns. In addition, eight of the nine eyes had a shallow macular traction detachment associated with PHT. CONCLUSION: Eyes with DME associated with PHT may have a shallow, subclinical, macular detachment. Optical coherence tomography may be useful in evaluating patients with DME to see if a macular detachment is present.     

Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction.

Pars plana vitrectomy with separation of the posterior hyaloid was performed in 10 eyes with diabetic macular edema and traction associated with a thickened and taut premacular posterior hyaloid. Nine of the 10 eyes had previous macular photocoagulation. Preoperative fluorescein angiography showed a deep and diffuse pattern of leakage in the macula. Intraoperatively, the attached and thickened posterior hyaloid was lifted and separated from the retina. Postoperatively, vision improved in nine eyes. The macular traction and edema resolved in eight eyes and decreased in two. Complications included a vitreous hemorrhage, a rhegmatogenous retinal detachment, cataract formation, and a mild epimacular membrane, each occurring in one eye. Vitreous surgery can improve the visual prognosis of some eyes with diabetic macular traction and edema associated with a thickened and taut posterior hyaloid.     

Spontaneous resolution of vitreomacular traction associated with diabetic macular edema

PURPOSE: Little information is available about the natural history of vitreomacular traction (VMT) associated with diabetic macular edema. A few cases of spontaneous resolution of VMT associated with diabetic macular edema have been described, but have not been documented by optical coherence tomography (OCT). The authors report the spontaneous resolution of VMT associated with diabetic macular edema 1 month after the end of panretinal photocoagulation therapy (PRP). METHODS: Case report: A 66-year-old woman presented with complicated proliferative diabetic retinopathy and diabetic macular edema associated with VMT, documented by OCT, in the right eye. Left eye examination showed complete PRP and ischemic maculopathy. PRP was immediately realized in the right eye in regard to the presence of complicated proliferative diabetic retinopathy. RESULTS: One month after the end of PRP, right eye visual acuity improved. OCT examination showed complete release of foveal posterior hyaloid traction, and significant reduction in foveal thickness. The follow-up was 1 year. At the end of follow-up, visual acuity slightly improved again; only a small residual foveal retinal thickening remained. CONCLUSIONS: The authors report spontaneous resolution of VMT associated with diabetic macular edema, probably facilitated by PRP, with concurrent reduction of macular thickness and visual improvement. As spontaneous resolution may occur in some eyes with diabetic macular edema associated with VMT, a period of observation after the end of the PRP may be considered prior to vitrectomy.     

Epiretinal pathology of diffuse diabetic macular edema associated with vitreomacular traction

PURPOSE: To investigate the ultrastructure of the vitreomacular interface in patients with diffuse diabetic macular edema (DDME) associated with vitreomacular traction. DESIGN: Laboratory investigation. METHODS: Fifty-five consecutive patients with DDME underwent vitrectomy with en-bloc removal of the inner limiting membrane (ILM) and epimacular tissue. Six patients were operated on both eyes. Sixty-one specimens harvested during vitrectomy were analyzed by electron microscopy. RESULTS: Preoperatively, a thickened premacular cortical vitreous was present in 47 eyes. Native vitreous collagen with single cells interspersed within the collagenous layer or a cellular monolayer were the ultrastructural features in these eyes. Twenty-three eyes showed an epimacular membrane. In eyes with obvious signs of tangential vitreomacular traction, multilayered membranes situated on a layer of native vitreous collagen were found. Fibroblasts and fibrous astrocytes were the predominant cell types; myofibroblasts and macrophages were also present. Sixty of 61 specimens showed native vitreous collagen covering the ILM. Macular edema resolved in 58 eyes and persisted in 3 eyes. No recurrent fibrocellular proliferation was observed during the follow-up period of 18 months (mean, 3 to 56 months). CONCLUSIONS: The vitreomacular interface in eyes with DDME is characterized by a layer of native vitreous collagen and a varying cellular component. Tangential vitreomacular traction is associated with multilayered membranes situated on a layer of vitreous collagen. Resolution of macular edema does not depend on the presence and removal of contractile membranes. In eyes without tangential traction, complete removal of epimacular tissue also leads to fluid resorption.     

Vitrectomy for traction macular edema

Purpose: Traction macular edema may develop through contraction of macular epiretinal membranes (ERM), or due to persistant vitreomacular traction during the evolution of vitreomacular traction syndrome (VMS). The purpose of this retrospective study was to determine the effect of vitreous surgery and the release of the vitreomacular traction or the removal of epiretinal membranes, on the evolution of traction induced macular edema. Material and methods: Fourteen eyes from 14 patients presenting with idiopathic or secondary epiretinal membranes, and 11 eyes from 10 patients presenting with vitreomacular traction syndrome, underwent vitrectomy for reduced vision and cystoid macular edema, identified by slit-lamp examination and fluorescein angiography. No coexistent ocular conditions that might have caused macular traction were present. History, preoperative eye examination, operative findings, postoperative course and final examination as well as pre- and postoperative fluorescein angiography were reviewed. Results: In the ERM group, cystoid macular edema disappeared in all cases during the postoperative period and the mean visual acuity (VA) at the end of the follow-up (0.48 ± 0.23) significantly increased compared to the preoperative one (0.29 ± 0.2) (p=0.004). In the group of patients suffering from VMS, the posterior vitreous traction on the macula was released and macular edema disappeared in all cases but one. The mean v.a. at the end of the follow-up (0.42 ± 0.24) significantly increased compared to the preoperative one (0.18 ± 0.1) (p=0.01). Complications included intraoperative small petechias and postoperative progressive nuclear sclerosis, retinal detachment and retinal pigment epitheliopathy. Conclusions: Cystoid macular edema may develop secondary to vitreomacular traction syndrome or epiretinal membrane contraction. Vitrectomy is effective in releasing macular traction which, in turn, may induce a decrease of the macular edema with improvement of visual acuity. This revised version was published online in July 2006 with corrections to the Cover Date.     

Branch retinal vein occlusion associated with vitreoretinal traction

CASE REPORT: Branch retinal vein occlusion (BRVO) is believed to arise at arteriovenous crossing sites. Surgical dissection of the arteriovenous sheath has been proposed as a treatment option, yet induction of a posterior vitreous detachment may be as important in obtaining a successful surgical outcome, suggesting that vitreoretinal traction may play a role in the development of BRVO. A retrospective review of 3 patients presenting with clinical features of BRVO and evidence of vitreoretinal traction at the occlusion site was conducted. COMMENTS: All patients presented with mild vitreous hemorrhage. Intraretinal hemorrhages were distributed in an unusual linear pattern along the involved venous segment, suggesting the presence of vitreoretinal traction. Fluorescein angiography demonstrated blocked fluorescence secondary to hemorrhage with delay of venous flow at the avulsion site. Partial avulsion of the involved venous segment was evident on clinical examination, B-scan ultrasound, or optical coherence tomography. Vitreoretinal traction may contribute to the pathogenesis of BRVO in some patients.     

频域OCT检查对黄斑水肿特点的分析

目的 通过频域OCT对黄斑水肿形态进行观察,了解水肿程度及分布情况,并分析水肿与视力的相关性.方法 选取患黄斑水肿患者25例29只眼,病例包括视网膜中央静脉阻塞所致为8例8只眼,视网膜分支静脉阻塞7例7只眼,葡萄膜炎4例4只眼,糖尿病性视网膜病变6例10只眼.年龄52-83(64.76±8.30)岁.最佳矫正视力(BCVA)0.05～1.0(0.35±0.12).利用最新一代频域RTVueFD-OCT对黄斑区进行扫描.结果 黄斑区15°范围内神经上皮厚度(453.00±103.12)μm,其中各区域神经上皮层厚度为:中心凹(533.10±115.23)μm,旁中心区(488.93±89.71)μm,中心凹边缘区(397.05±83.52)μm.不同区域神经上皮层厚度比较差异有统计学意义(F=2.937,P<0.01),黄斑区中心凹区神经上皮层厚度与中心凹边缘区神经上皮层厚度比较差异有统计学意义(与上、下、鼻、颞侧比较结果P<0.01,以中心凹区最厚,依次为下、上、颞、鼻侧边缘区).而中心凹神经上皮层厚度与旁中心凹区神经上皮层厚度比较差异无统计学意义与上、下、鼻、颞侧比较结果P>0.05.患者BCVA与中心凹神经上皮层厚度间存在负相关关系(r=-0.784,P<0.01),与旁中心凹区神经上皮层厚度间无相关关系(r=-0.134,P>0.05),与中心凹边缘区神经上皮层厚度间无相关关系(r=.275,P>0.05).结论 频域OCT能够精确地对黄斑水肿进行活体组织学成像,具有简便、非侵入性、重复性好等特点.     

Pretreatment clinical variables associated with the response to intravitreal bevacizumab (Avastin) injection in patients with persistent diabetic macular edema

Background

The purpose of the study is to determine whether the pre-treatment clinical systemic variables and optical coherence tomography (OCT) findings are associated with the subsequent response to the intravitreal bevacizumab (IVB) in eyes with persistent diabetic macular edema (DME).

Design

Prospective, interventional non-comparative case series study.

Methods

38 Patients (45 eyes) with refractory diabetic macular edema; 16 females, 22 males with a mean aged 57.5 year. All patients had persistent DME not responded to other forms of treatments. Complete eye examination; best corrected visual acuity (BCVA) (represented as LOGMAR for adequate statistical analysis), slit-lamp exam, intraocular pressure measurement, stereoscopic biomicroscopy of the macula, and morphologic patterns of diabetic macular edema demonstrated by OCT.All patients had intravitreal injection of 0.05 mL = 1.25 mg bevacizumab (Avastin; Genentech, Inc., San Francisco, CA), and were followed up for 3 months. The pre and post-injection follow-up data were analyzed by Student-t test and Mann–Whitney test for two main outcome measures; visual acuity (LOGMAR) and central foveal thickness (CFT) changes over a period of three months, and the data included demographic factors, type, duration and the control of diabetes mellitus (HbA1C%), grade of diabetic retinopathy, renal function (serum creatinine level), serum cholesterol, blood pressure control and previous treatment by focal laser and/or intravitreal triamcinolone injection.

Results

The LOGMAR and central foveal thickness (CRT) improved in 30/45 eyes (67%) and 32/45 eyes (72%), respectively during a mean follow-up time of three months. The mean LOGMAR visual acuities were 0.64 (SD ± 0.34), 0.61 (SD ± 0.31) and 0.60 (SD ± 0.32) at pre-injection, at 1 month post-injection and at 3 months post-injection, respectively; but this mean increase in vision was statistically not significant (P value = 0.099). The mean foveal thicknesses were 444.95 μm (SD ± 127.36), 394.95 μm (SD ± 138.03) and 378.32 μm (SD ± 112.01) at pre-injection, 1 month post-injection and 3 months post-injection, respectively, this decrease in the foveal thickness was statistically significant (P value <0.001). The pre and post-injections values of the variables for diabetic duration, diabetic control (HbA1c) and OCT pattern of macular edema showed significant statistical correlations (P < 0.05) with LOGMAR only, however the values of the variables for serum creatinine and cholesterol show statistical correlation (P < 0.05) with both LOGMAR and CFT.

Conclusions

Chronicity and inadequate control of diabetes mellitus, nephropathy, hyperlipidemia and presence of vitreomacular attachment (VMA) are factors associated with poor vision progress after intravitreal bevacizumab injection.