第7例——左眼视力下降伴视物变形一年

病历摘要 患者男性，26岁。因左眼视力下降伴视物变形1年，于2005年9月28日来我院就诊。既往患者有高血压病史，幼年时曾行双肾上腺嗜铬细胞瘤切除术，其母和姐均患相同疾病。眼部检查：矫正视力右眼为1.2（-4.00DS），左眼为0.2（-4.00DS）；     

影响1区早产儿视网膜病变激光治疗结果的因素分析

目的　观察影响1区早产儿视网膜病变（ROP）激光治疗效果的相关因素。方法　回顾性分析35例1区ROP患儿 69只眼的临床资料。所有患儿均经过间接检眼镜检查确诊,根据病变在视网膜的位置分为前部1区和后部1区,分别为49、20只眼。69只眼中急进性ROP（AP-ROP）12只眼,前部1区4只眼,后部1区8只眼。在+20 D透镜辅助以及巩膜压迫器压迫下,采用二极管间接检眼镜激光对嵴前周边视网膜无血管区进行激光光凝,随访观察时间2～48个月,平均观察时间（10.85±11.35）个月。嵴消退,病情稳定为治愈;视网膜病变进展为4期或5期为视网膜病变进展。结果　69只眼中,治愈42只眼,占60.87%;视网膜病变进展27只眼,占39.13%。前部1区49只眼中,治愈34只眼,占69.38%;进展15只眼,占30.62%。后部1区20只眼中,治愈8只眼,占40.00%;进展12只眼,占60.00%。前部1区和后部1区视网膜病变进展率比较,差异有统计学意义（χ2=5.15,P＜0.05)。AP-ROP 12只眼中激光光凝后视网膜脱离9只眼。发现视网膜病变进展的时间在激光光凝治疗后2～18周。Logistic回归分析表明,激光光凝治疗后ROP的进展与治疗前视网膜纤维血管网的范围有关（回归系数0.235,P=0.00）,与早产儿的出生体重（回归系数0.000,P=0.091）、胎龄（回归系数-0.037,P=0.359）、激光治疗时矫正胎龄（回归系数0.013,P=0.651）及激光光凝点数量（回归系数-5.7E-0.05,P=0.800）的多少无关。结论　1区ROP激光光凝治疗有效,前部1区的激光光凝治疗预后较后部1区好;激光光凝治疗后的视网膜病变进展与治疗前视网膜纤维血管网范围有关。     

新生血管性青光眼治疗面临的临床问题与思考

新生血管性青光眼(NVG)属于难治性青光眼,治疗效果差,很多患眼最终丧失视功能.目前临床上面临的主要问题是:(1)NVG的治疗目标是什么？是以降眼压为目的还是以保留视功能为目的？(2)如何创造条件对NVG的原发病变进行治疗？(3)究竟何种手段是NVG治疗的关键？是抗血管内皮生长因子(VEGF)药物应用、抗青光眼手术还是严格控制导致视网膜缺血因素的全视网膜光凝(PRP)?(4)如何建立治疗NVG的综合策略？本文中提出以保留视功能为核心治疗目的、以完成PRP为目标、以抗VEGF治疗和抗青光眼手术为关键手段的NVG综合治疗策略,其宗旨是最大限度地挽救患者的视功能.     

兔眼视网膜二极管激光和氩离子激光光凝反应的比较

目的 比较二极管激光和氩离子激光光凝后不同级别光斑与视网膜组织学改变,以指导二极管激光在临床的使用。方法 23只青紫蓝兔42只眼,按不同光斑级别和光凝后不同时间分组,分别行二极管激光和氩离子激光光凝,光镜下观察、比较其组织学改变及定量图像分析。结果 两种激光同级光斑组织学改变比较,急性期2,3级光斑均无明显差异,恢复期2级光斑二极管激光病灶外核层细胞全部萎缩消失,而氩激光仅表现为外核层细胞减少。图像分析显示两种激光同级光斑即刻组面积均值二极管激光均明显大于氩离子激光（P＜0．05）,但光凝后1天的面积增长率二极管激光（8％）明显低氩激光（23％）。结论 810nm二极管激光可以起到氩激光等同的治疗作用,而且其迟发损伤反应小于氩激光,使用安全。     

努力探索发病机制,进一步提升治疗水平:中心性浆液性脉络膜视网膜病变研究的现实与挑战

中心性浆液性脉络膜视网膜病变(中浆)的治疗理念随着对中浆认识的逐步深入而演变.最初临床研究发现,中浆属自限性疾病,所以,主张观察或保守治疗通过荧光素眼底血管造影的进一步研究发现,中浆是视网膜色素上皮(RPE)屏障功能受损导致的浆液性RPE和(或)神经视网膜脱离,激光光凝治疗可以通过激光的热效应凝固RPE渗漏点从而达到治疗目的;吲哚青绿血管造影用于中浆的临床研究后新近发现,中浆病灶对应处脉络膜血管通透性增加,导致脉络膜组织内静水压过高引发局部RPE脱离,进而机械性破坏RPE屏障才是其病理基础的主要原因.光动力疗法可以栓塞脉络膜毛细血管网,从而阻止脉络膜毛细血管通透性增加导致的渗漏,可以取得其治疗成功.然而,关于中浆发病机制和治疗的探索远未结束.进一步探讨其发病机制,提高临床诊断治疗水平,既是临床工作的迫切需要,也是挑战眼科医生智慧的重大问题.促进更多更好的中浆临床和基础研究成果早El问世需要我们共同努力.

Abstract：

The concept of treatment of central serous chorioretinopathy (CSC) has evolved dramatically with the understanding of its pathogenesis recently. Initial clinical studies found that CSC is a self-limiting disease, therefore advocated observation or conservative treatment was recommended. Further study by fundus fluorescein angiography indicated that CSC results from barrier dysfunction of retinal pigment epithelium (RPE), which leads to serous RPE and (or) neural retinal detachment; so laser photocoagulation to close RPE leakage points by its thermal effects became a strategy to treat CSC. Recent study by indocyanine green angiography revealed that increased choroidal vascular permeability can induce high hydrostatic pressure and focal RPE detachment, resulting in mechanical breakage of RPE barrier. This is likely the major pathological basis of CSC now. Photodynamic therapy (PDT) can embolize of choroidal capillary network, thereby preventing choroidal leakage caused by increased capillary permeability, and thus cure the CSC. However the search for the pathogenesis and better treatment of CSC is far from over.Further investigation about pathogenesis and improvement of diagnosis and treatment is an urgent need for clinic work, but also major issues challenging the wisdom of an ophthalmologist. We need to work together to promote more and better clinical and basic research of CSC.     

新生血管性青光眼治疗策略的初步探讨

目的 建立以完成全视网膜光凝为目标,抗VEGF治疗和抗青光眼手术为核心治疗手段的新生血管性青光眼(neovascular glaucoma,NVG)的综合治疗方法,探讨NVG的治疗策略.方法 设计NVG治疗流程,纳入NVG患者9例10只眼进行综合治疗,治疗方法包括药物降眼压、眼内抗VEGF治疗、单独或联合白内障及玻璃体切割手术的抗青光眼手术以及在此基础上完成全视网膜光凝治疗.随诊6～18(平均9.7)个月,观察患者眼压、视功能及虹膜及房角新生血管状况.结果 本组患者治疗前眼压(42.30±10.25)mmHg,治疗后末次随诊眼压(17.30±4.86)mmHg,统计学分析差异具有统计学意义(P＜0.001).治疗后7只眼视力明显提高.末次随诊时8只眼虹膜及房角新生血管消退.结论 以完成全视网膜光凝为目标,抗VEGF治疗和抗青光眼手术为手段的NVG综合治疗方法能有效控制患者眼压并最大限度保护患者的视功能.

Abstract：

Objective To establish the efficacy and safety of comprehensive therapy for neovascular glaucoma (NVG) by which the main goal is to complete pan-retinal photocoagulation (PRP) and the core treatment is anti-VEGF injection/anti-glaucoma operation,and to discuss the treatment strategies.Methods To design a medical treatment process for NVG.Ten eyes of 9 patients treated with comprehensive therapy including medications for decreasing intraocular pressure (IOP),combination cataract remove/vitrectomy/anti-glaucoma operation or anti-glaucoma operation alone and compete PRP after all the basis treatment.To observe IOP,visual function and anterior chamber angle neovascularization for 6-18 months follow-up (average,9.7months).Results The mean IOP was 42.30 mmHg (± 10.25) before treatment,and the mean IOP was 17.30mmHg (± 4.86) after treatment.The difference had statistic significance (P＜0.001).Visual acuity of 7 eyes was improved significantly after treatment.Iris and anterior chamber angle neovasculization of 8 eyes were regressed completely at the last follow-up.Conclusions IOP is well controlled and visual function is preserved maximum with comprehensive therapy for NVG by completing PRP and anti-VEGF/anti-glaucoma operation.     

玻璃体黄斑牵引综合征的手术疗效观察

目的 探讨玻璃体手术治疗玻璃体黄斑牵引综合征的临床效果及光相干断层扫描、荧光素眼底造影对手术疗效的评价.方法 经裂隙灯前置镜、间接眼底镜检查、B超、光相干断层扫描(OCT)、荧光素眼底血管造影(FFA)等检查确诊为玻璃体黄斑牵引综合征行玻璃体手术的患者30例(30只眼)的临床资料进行回顾性分析.结果 30只眼经手术解除玻璃体对黄斑部的牵引.术后20只眼视力提高.术后黄斑区牵引处OCT测量高度平均减小267μm,有明显改善.术前荧光素眼底血管造影检查存在黄斑囊样水肿伴渗漏,术后明显减轻.术前合并高度近视眼者视力预后不佳.结论 玻璃体手术能够有效解除玻璃体对黄斑部的牵引,阻止患者视力进一步下降,减轻黄斑水肿及渗漏,是治疗玻璃体黄斑牵引综合征的有效方法.光相干断层扫描及荧光素眼底造影检查可以对手术疗效进行评价,有利于术后随访.

Abstract：

Objective To evaluate the efficacy of vitreous surgery for patients with vitreomacular traction syndrome. Methods Of 30 patients (30 eyes) who underwent vitrectomy for vitreomacular traction syndrome were retrospectively analyzed. Results Vitreomacular traction was released successfully, and a better visual acuity was obtained in 20 eyes. Mean macular thickness decreased by 267μ m postoperatively. The eyes showed statistically significant improvement in visual acuity and central macular thickness (P <0.05). Optical coherence tomography (OCT) and fluorescein fundus angiography (FFA) showed macular edema gradually alleviated after vitreous surgery. Preoperative high myopia was associated with prognosis of postoperative visual acuity (P<0.05). Conclusions Vitrectomy can relieve macular traction, and is effective for decreasing macular thickness and improvement of vision in vitreomacular traction syndrome. OCT and FFA are useful for evaluation and follow-up for vitreomacular traction syndrome.     

GM6001的玻璃体代谢及视网膜毒性作用的研究

目的：评价人工合成的金属蛋白酶抑制剂GM6001在玻璃体中的代谢及其眼内安全性。方法：选择健康成年的青紫蓝兔16只，随机分成4组，右眼分别玻璃体房注射GM6001各0．05mL（A组100μmol、B组75μmol、C组50μmol和D组25μmol）。左眼分别注射PBS0．05mL作为对照。各组术后不同时间取玻璃体样本，应用高效液相色谱分析仪检测其中GM6001的浓度。术前术后进行裂隙灯、间接检眼镜和视网膜电图（ERG）检查，最后处死动物对视网膜进行光镜及透射电镜的检查。结果：术后前3d，玻璃体房GM6001浓度下降迅速，而后保持缓慢降低至术后28d完全清除。术后裂隙灯、间接检眼镜、ERG检查、视网膜光镜及透射电镜观察，各组均未发现异常改变。结论：GM6001在玻璃体房注射对视网膜是安全的。GM6001在单次玻璃体房注射后2wk可维持有效浓度。