视网膜色素变性的临床实践指南

视网膜色素变性(retinitis pigmentosa,RP)是一类由视杆细胞首先受累为主的进行性遗传性视网膜变性疾病。初期以视杆细胞功能异常为主,同时或随后可合并视锥细胞功能异常。随着疾病的进展,视功能进行性受损,直至全盲,眼底出现以色素异常为主的多种形态的视网膜变性改变。RP具有高度的遗传异质性和表型多样性。已发现的致病基因有90个。本指南从RP的病因与发病机制、疾病诊断、临床咨询等方面进行总结,旨在规范其临床诊疗,供临床医师参考。     

The RUSH2A Study: Dark-Adapted Visual Fields in Patients With Retinal Degeneration Associated With Biallelic Variants in the USH2A Gene

PurposeTo measure visual fields using two-color dark-adapted chromatic perimetry in a subset of participants in the Rate of Progression of USH2A-related Retinal Degeneration (RUSH2A), a study of USH2A-mediated syndromic (USH2) and autosomal recessive nonsyndromic retinitis pigmentosa, determine percentage retaining rod function, and explore relationships between dark-adapted visual fields (DAVF) and rod function from ERG and full-field stimulus thresholds (FST).MethodsFull-field rod mean sensitivity, number of rod loci, maximum sensitivity, DAVF full-field hill of vision (DAVF V_TOT), and 30° hill of vision (DAVF V₃₀) were measured in one eye for DAVF ancillary study participants (n = 49). Loci where cyan relative to red sensitivity was more than 5 dB on dark-adapted chromatic perimetry were considered rod mediated. Correlation coefficients between the DAVF measures and standard clinical measures were estimated, as were kappa statistics (κ) for agreement between DAVF and other measures of rod function.ResultsOf 49 participants tested with DAVF, 38 (78%) had evidence of rod function, whereas 15 (31%) had measurable rod ERGs. DAVF maximum sensitivity was highly correlated with FST white thresholds (r = −0.80; P < .001). Although not statistically significant, the number of rod loci and DAVF V_TOT were lower in eyes with longer disease duration by 0.82 (95% confidence interval, −1.76, 0.12) loci/year and 0.59 (95% confidence interval, −1.82, 0.64) dB-steradians/year, respectively.ConclusionsRod-mediated function on FST and DAVF is present in many patients with symptomatic USH2A-related retinal degeneration, including some without measurable rod ERGs. RUSH2A longitudinal data will determine how these measures change with disease progression and whether they are useful for longitudinal studies in inherited retinal degenerations.     

RCS大鼠视网膜色素变性过程中视网膜形态学研究

目的研究遗传性视网膜色素变性大鼠(Royal College of Surgeons rat,RCS rat)在视网膜变性发展过程中视网膜形态学变化.方法 RCS-p (视网膜含色素的变性大鼠)按出生后视网膜变性的发展状况分为变性早期(RCS15 d)、中期(RCS 30 d)、晚期(RCS90 d)3个时相点,分别采用相应时期的RCS-rdy p (视网膜含色素的正常大鼠)作为对照组(control groups,C 15 d,C 30 d,C 90 d),每组5眼,取各组大鼠眼球进行视网膜切片,行HE染色,采用MIAS-1000图像分析系统在400倍光镜下测视网膜外节(OS)、外核层(ONL)以及内核层(INL)厚度.结果①视网膜感光细胞随着病变的发展逐渐变性死亡,晚期视网膜色素上皮层和感光细胞层结构紊乱,但光镜下观察内核层、神经节细胞层仍保持较正常的形态.②与对照组比较,RCS大鼠视网膜色素变性过程中感光细胞外节膜盘堆积,外核层变薄,内核层在变性中期增厚,早期及晚期变薄.结论①RCS大鼠病变发展过程中视网膜各层神经元形态改变的不一致性.②变性中期视网膜内核层较对照组增厚,可能与该时期内核层神经元缺乏前级神经元的信号输入致细胞突起反应性增生,产生视网膜形态重构(remodeling)有关.     

Dominant Leber congenital amaurosis,cone‐rod degeneration,and retinitis pigmentosa caused by mutant versions of the transcription factor CRX

We summarize 18 mutations in the human CRX gene that have been associated with Leber congenital amaurosis (congenital retinal blindness), cone‐rod degeneration, or retinitis pigmentosa. Except for one obviously null allele not definitely associated with a phenotype (a frameshift in codon 9), all CRX mutations appear to be completely penetrant and cause disease in heterozygotes. These dominant alleles fall into two categories. In one group are missense mutations and short, in‐frame deletions; in the second group are frameshift mutations, all of which are in the last exon. All of these dominant mutations are likely to produce stable mRNA that is translated. Mutations in the missense group preferentially affect the conserved homeobox (codons 39–98), and all frameshift mutations leave the homeodomain intact but alter the OTX motif encoded by codons 284–295 at the carboxy terminus. We could not uncover any correlation between type of disease (congenital amaurosis vs. cone‐rod degeneration or retinitis pigmentosa) and the type of mutation (missense vs. frameshift). Four of the 18 mutations (～20%) were de novo mutations, and all of these were found in isolate cases of Leber congenital amaurosis. Dominant CRX mutations have not been associated with mental retardation or developmental delay that has sometimes been found in Leber congenital amaurosis caused by other genes. Implications regarding potential future therapies are discussed. Hum Mutat 18:488–498, 2001. © 2001 Wiley‐Liss, Inc.     

常染色体显性遗传视网膜色素变性家系的分子遗传学研究

目的对1例4代常染色体显性遗传视网膜色素变性家系进行致病基因定位,并对候选基因进行突变筛查。方法收集1例视网膜色素变性家系,抽取家系成员外周血并提取DNA,用连锁分析法对与疾病相关联的22个已知基因进行定位,并对定位区域内的候选基因进行突变筛查。结果两点连锁分析结果显示,在微卫星标记D7S484处取得最大LOD值为1.51（θ=0.00时）;聚合酶链反应直接测序法筛查候选基因RP9,未发现突变。结论该家系可能存在RP9基因大的碱基缺失突变或基因重排,也可能存在1个新的致病基因。     

Transplantation of bone marrow-derived mesenchymal stem cells rescue photoreceptor cells in the dystrophic retina of the rhodopsin knockout mouse

Background Retinitis pigmentosa belongs to a large group of degenerative diseases of the retina with a hereditary background. It involves loss of retinal photoreceptor cells and consequently peripheral vision. At present there are no satisfactory therapeutic options for this disease. Just recently the use of mesenchymal stem cells has been discussed as one therapeutical option for retinal degeneration, as they have been shown to differentiate into various cell types, including photoreceptor cells. In this article we wanted to investigate the potency of mesenchymal stem cells to induce rescue effects in an animal model for retinitis pigmentosa, the rhodopsin knockout mouse. Methods For the experiments, three experimental groups of 10 animals each were formed. The first group consisted of untreated rhodopsin knockout (rho^-/-) animals used as controls. The second group consisted of rho^-/- mice that had received an injection of mouse mesenchymal stem cells, which were transduced using an adenoviral vector containing the sequence for the green fluorescent protein (GFP) prior to transplantation. In the third sham group, animals received an injection of medium only. Thirty-five days after transplantation, GFP-expressing cells were detected in whole-mount preparations of the retinas as well as in cryostat sections. For the detection of rescue effects, semi-thin sections of eyes derived from all experimental groups were produced. Furthermore, rescue effects were also analysed ultrastructurally in ultrathin sections. Results Histological analysis revealed that after transplantation, cells morphologically integrated not only into the retinal pigment epithelium but also into layers of the neuroretina displaying neuronal and glial morphologies. Furthermore, significant rescue effects, as demonstrated by the occurrence of preserved photoreceptor cells, were detected. Conclusions Our data indicate that mesenchymal stem cells can prolong photoreceptor survival in the rhodopsin knockout mouse, also providing evidence of a therapeutical benefit in retinitis pigmentosa. This work was funded by “Pro Retina”.     

关注我国葡萄膜炎的病因和类型的变化

本文旨在阐述我国葡萄膜炎的常见类型、主要致盲类型及新近出现或增多的一些类型,指出Vogt-小柳原田综合征和Beh(c)et病是我国常见的葡萄膜炎主要致盲类型,梅毒、结核、真菌性葡萄膜炎或眼内炎的发病逐渐增多,艾滋病所致的机会性感染尤其是巨细胞病毒性视网膜炎呈现上升的发病趋势,眼内-中枢神经系统淋巴瘤、视网膜母细胞瘤及恶性肿瘤眼内转移所致的伪装综合征的发生也有所增加.     

Reported effects of non‐traditional treatments and complementary and alternative medicine by retinitis pigmentosa patients

Background: Benefits of complementary and alternative medicine (CAM)‐related interventions have been demonstrated for patients with chronic, systemic diseases in which stress, anxiety and disability are prevalent. Subjects with retinitis pigmentosa (RP) commonly indicate that they have ‘good’ and ‘bad’ vision days, stating that stress causes a decrease in vision and that vision improves when the stress is alleviated. We assessed CAM use by RP patients and its perceived effectiveness. Methods: We enquired about nine CAM areas: meditation, mind‐body therapies, yoga, movement therapies, energy therapies, acupuncture, massage therapy, spirituality/religion and herbal therapies/aromatherapy. Ninety‐six RP patients with any level of vision completed an anonymous internet survey. Results: Ninety‐five per cent of respondents tried at least one of the nine CAM areas. Seventy‐five per cent have used nutritional supplements, including lutein (47 per cent), bilberry (32), vitamin A palmitate (36) and docosahexaenoic acid (23 per cent). Some tried meditation (47) and yoga (31 per cent). Stress and anxiety levels were reported as improved in 93, 92 and 87 per cent of those who used yoga, meditation and mind‐body therapies, respectively. Many of those who tried mind‐body therapies (40) or acupuncture (50 per cent), used it with a desire to fight RP. Vision was subjectively affected in 65 per cent of acupuncture users and from 20 to 35 per cent of the users of the other CAM areas. Those who indicated that their vision was affected by at least one type of CAM (35 per cent) were statistically significantly more likely to require magnification to read (that is, they had lost more vision and RP had progressed), than those who did not believe vision was impacted (59 versus 84 per cent). Conclusions: RP patients are using CAM and are experiencing some impact on vision and physical/emotional well‐being. Clinicians and researchers should be aware of its use. Clinical trials with CAM interventions are necessary to attempt to validate these findings.     

细胞因子信号抑制因子在实验性自身免疫性葡萄膜视网膜炎外周血单个核细胞内的表达变化

目的 观察和探讨细胞因子信号抑制因子（SOCS)在实验性自身免疫性葡萄膜视网膜炎（EAU）外周血单个核细胞（PBMC）内的表达及意义。方法 光感受器间维生素A 类结合蛋白(IRBP)免疫100只Lewis大鼠诱导EAU动物模型，随机分为对照组和治疗组。治疗组从免疫后第1天至第28天，给予环孢霉素A（CSA）灌胃，20 mg/（kg·d）；对照组给予等量生理盐水。免疫前、免疫后7、14、21、28 d采用裂隙灯显微镜观察大鼠眼部变化并抽取其心脏血，酶联免疫吸附试验（ELISA）方法检测血清白细胞介素（IL）-4、IL-12、干扰素（IFN）-γ的含量；实时荧光定量聚合酶链反应（PCR）和蛋白免疫印迹法检测PBMC内SOCS mRNA和蛋白表达。结果免疫后14 d 时炎症最明显。对照组可见明显的虹膜睫状体炎，治疗组前房轻微炎性渗出，但无虹膜后粘连及前房积脓。对照组血清中 IL-12、IFN-γ免疫后14 d达到最高峰，28 d下降到基础水平，治疗组在免疫后14 d达到高峰，但是升高程度明显低于对照组，其他时间点与免疫前比较无差异；IL-4在对照组中下降不明显，治疗组在整个病程中呈上升趋势。SOCS1、SOCS5 mRNA免疫后14 d表达最高，对照组分别是免疫前的4.05和3.83倍，治疗组分别为1.15和1.16倍；两组中含SH2结构的细胞因子诱导蛋白（CIS）与SOCS3 mRNA轻度升高，对照组较治疗组略明显。对照组中SOCS1、SOCS5蛋白在免疫后7、14、21 d时显著高于免疫前，CIS、SOCS3蛋白在免疫后14、21 d显著高于免疫前；治疗组中仅SOCS1蛋白在免疫后14 d显著高于免疫前，其他时间点较免疫前无明显改变。 结论 SOCS1、SOCS5水平升高与EAU发生过程中的Th1型反应增强有关，CIS、SOCS3水平轻度升高可能是存在着Th2细胞反应的增强以对抗Th1细胞反应，实现动态免疫平衡。     

中医药治疗原发性视网膜色素变性的临床观察

目的观察中医药治疗原发性视网膜色素变性的临床疗效。方法采用补肾养血明目汤加减,静脉滴注舒血宁和生脉注射液,口服银杏叶片、生脉颗粒及针灸等综合治疗视网膜色素变性64例（128只眼）。结果好转63只眼,无效65只眼,有效率为49%。结论中医药治疗原发性视网膜色素变性是有效的方法。