间接检眼镜下激光光凝治疗青少年型Coats病

目的 探讨间接检眼镜下激光光凝治疗青少年型Coats病的效果和预后。方法 临床检查确诊为青少年型Coats病患儿19例19只眼纳入研究。首诊年龄27.0～146.0个月，平均年龄73.5个月。最佳矫正视力（BCVA）≥0.1者7 只眼；0.01～0.09者8只眼；数指3只眼；光感1只眼。所有患眼渗出均累及黄斑。黄斑渗出性视网膜脱离3只眼；黄斑下纤维化4只眼；黄斑轻度萎缩1只眼。渗出范围大于2个象限17只眼；小于2个象限2只眼。所有患眼均可见不规则扩张、纡曲、纽结的异常血管。其中，异常血管位于正上方或鼻上方2只眼；位于颞侧或颞下方17只眼。渗出性视网膜脱离13只眼。其中，未累及黄斑10只眼；累及黄斑3只眼。在全身麻醉下，应用双目间接检眼镜激光输出系统对异常的视网膜血管及伴明显渗漏的视网膜进行激光光凝。渗出性视网膜脱离范围广、脱离高度高者合并玻璃体腔注射曲安奈德2 mg 3只眼。治疗后6～51个月内随访视力、视网膜异常血管消退、视网膜下渗出吸收以及渗出性视网膜脱离复位的情况。结果 行玻璃体腔注射曲安奈德2 mg治疗的3只眼，异常血管明显消退、渗出明显减少，但因并发白内障，行白内障摘除手术1只眼；出现黄斑前增生膜，行前膜剥除术1只眼。随访期末，所有患眼异常血管均消退。黄斑外渗出完全吸收8只眼，其中黄斑渗出完全吸收4只眼；渗出明显减少9只眼；渗出无明显改变2只眼。渗出性视网膜脱离13只眼中，视网膜复位8只眼；脱离范围减少3只眼；无明显改变2只眼。渗出未完全吸收15只眼；黄斑下纤维化9只眼；黄斑轻度萎缩3只眼；后期病变区视网膜萎缩伴色素沉着，血管可闭塞成白线状。BCVA≥0.1者6只眼；0.01～0.09者11只眼；数指1只眼；光感1只眼。BCVA无变化15只眼；提高2只眼；下降2只眼。治疗结束时，患眼和对侧健康眼的球镜度数比较结果显示，患眼球镜度数高于对侧健康眼（t=3.6，P=0.003）。患眼和对侧健康眼的柱镜度数比较结果显示，患眼散光度数高于对侧健康眼（t=3.6, P=0.004）。但所有患眼矫正屈光度后视力无提高。结论 间接检眼镜下激光光凝治疗青少年型Coats病，可有效控制病变进展，且对患儿损伤小，出现并发症的风险低。眼内注射曲安奈德是有效的辅助手段，但并发症多，应用需谨慎。

Juvenile Coats disease successfully managed with green diode laser using indirect ophthalmoscope

Objective To study the effects and outcomes of green diode laser therapy under indirect ophthalmoscope in the treatment of juvenile Coats disease. Methods Nineteen juvenile Coats disease patients (19 eyes) well enrolled in this study. Average age at presentation was 73.5 months (27 - 146 months). Best corrected visual acuity (BCVA) was ≥0.1 in 7 eyes; 0.01 to 0.09 in 8 eyes; counting finger in 3 eyes and light perception in 1 eye. The macular of all eyes was involved. There were 3 eyes with macular exudative retinal detachment, 4 eyes with sub macular fibrosis, 1 eye with macular atrophy. Exudative area was more than two quadrants in 17 eyes, and less than two quadrants in 2 eyes. The abnormal blood vessels located in the superior or nasal superior retina (2 eyes) or inferior or temple inferior area (17 eyes). Exudative retinal detachment occurred in 13 eyes, in which macular was not involved in 10 eyes, and macular was involved in 3 eyes. All patients were treated with green diode laser (532 nm) ablation therapy under general anesthesia and indirect ophthalmoscope to areas of the retina telangiectasia. 3 patients received a single intravitreal 2 mg triamcinolone injection (IVTA). Average follow up was 18.5 months (6 -51 months). Main outcome measures included visual acuity, retinal vascular abnormalities, subretinal exudates and exudative retinal detachment. Results Among 3 patients treated with IVTA, one needed cataract extraction and one needed pre-retinal membrane peeling surgery. After laser photocoagulation, resolution of telangiectasia lesions was achieved in all patients at the end of follow-up. Exudation was resolved in 8 eyes, reduced in 9 patients and no change in 2 eyes. Exudative detachment was resolved in 8/13 eyes, reduced in area in 3/13 eyes and no change in 2 eyes. There were 9 eyes with sub macular fibrosis and 3 eyes with macular atrophy at the end of follow-up. The visual acuity was stable in most cases. BCVA was ≥0.1 in 6 eyes; 0.01 to 0.09 in 11 eyes; counting finger in 1 eyes and light perception in 1 eye. Compared to the normal eyes, eyes with Coats disease tended to be more hyperopic (t=3.6，P=0.003) and astigmatic (t=3.6, P=0.004), but no correction were needed for these refractive errors. Conclusions Green diode laser therapy under indirect ophthalmoscope can be an effective treatment for juvenile Coats disease with little complications. IVTA can be helpful, but must be used with cautions as it can induce some complications.