视网膜中央静脉阻塞与糖尿病视网膜病变所致新生血管性青光眼的临床特点分析

摘要

背景 新生血管性青光眼(NVG)是一种可迅速致盲的难治性疾病,而引起NVG的主要病理机制是不同原发病导致的缺血性视网膜病变,以视网膜中央静脉阻塞(CRVO)和糖尿病视网膜病变(DR)居多,二者引起的NVG的临床特点不同,目前这方面的研究报道较少.目的 探讨和比较CRVO与DR引起NVG的临床特点及发展规律,为NVG的有效防治提供依据.方法 采用系列病例观察的方法,收集2009年1月至2012年6月在青岛大学医学院附属海慈医院眼科治疗的由CRVO和DR引起的NVG患者27例29眼,其中由CRVO引起者10例10眼,由DR引起者17例19眼.对两种NVG患者的原发病病程、NVG病程、眼压、眼底表现及治疗后的并发症进行分析和对比.所有患者均接受全视网膜光凝术、改善微循环治疗、抗青光眼(药物和手术)及原发病治疗,部分患者接受了玻璃体切割或/和白内障摘出术,每组患者中均有2眼接受雷珠单抗玻璃体腔内注射.两组患者随访时间分别为(14.00±10.13)个月和(17.89±12.52)个月,差异无统计学意义(t=-0.83,P＞0.05). 结果 CRVO和DR所致的NVG患者原发病病程的中位数分别为3.3个月(2周～6个月)和11.1个月(4～36个月),两组间差异有统计学意义(Z=-2.40,P＜O.05).CRVO所致NVG患者的病情进展快,而DR所致NVG患者的病情进展稍慢.CRVO所致10例10眼NVG者中,治疗后视力升高者2眼,视力不变或下降者8眼；而DR所致NVG的17例19眼中,治疗后视力升高者15眼,视力不变或下降者4眼,二者比较,差异有统计学意义(x2=9.38,P＜0.01).两组患者治疗前的眼压分别为(48.40±7.96) mmHg(1 mmHg=0.133 kPa)和(25.34±10.51)mmHg,治疗后分别为(11.40±5.15) mmHg和(16.42±3.63) mmHg,两组患者治疗前后的眼压差比较差异有统计学意义(t=6.30,P＜0.01).CRVO所致NVG患者治疗前6眼可见视盘水肿、视网膜出血水肿和静脉扩张,4眼可见轻度视盘水肿及视网膜出血；治疗后4眼眼底窥不见,2眼隐约见视盘苍白,视网膜陈旧性激光斑,2眼视盘苍白,视网膜血管闭塞,2眼视网膜动脉呈银丝状.DR所致NVG患者中治疗前8眼眼底窥不见,11眼眼底呈DRⅢ～Ⅳ期改变；治疗后16眼眼底病变稳定,3眼眼底病变发展到V～Ⅵ期.两组患者治疗后并发症的发生率分别为100.0％和21.1％,两组比较,差异有统计学意义(x2 =5.18,P＜O.05). 结论 CRVO与DR引起NVG的临床特点有所不同,可以依据两种NVG患者不同的临床表现来指导NVG的防治.%Background Neovascular glaucoma (NVG) is a serious ocular disease which may cause blindness.The primary pathogenesis of NVG is ischemic retinopathy derived by central retinal vein occlusion (CRVO) and diabetic retinopathy (DR).Clinical characteristics of NVG are variable based on the difference of primary diseases,such as CRVO and DR.However,there is a few studies regarding the diffcrcnces of NVG initiated by CRVO and DR.Objective This study was to compare the clinical characteristics in NVG patients secondary to CRVO and DR.Methods A series case observational study was carried out in Hiserve Hospital of Qingdao University from January 2009 to June 2012.Twenty-nine eyes of 27 patients with NVG caused by CRVO (10 eyes of 10 patients) and DR (19 eyes of 17 patients) were included.The history of underlying diseases,course of NVG,intraocular pressure(IOP),fundus findings and complications after treatment were analyzed and compared between the CRVO-derived NVG and DR-derived NVG.All patients underwent panretinal photocoagulation,improving microcirculation therapy,anti-glaucoma (drug or surgery) and causative disease treatment,and some of them received vitrectomy or/and cataract surgery.Two eyes from each group received intravitreal injection of ranibizumab.The follow-up time in both groups was (14.00±10.13) months and (17.89±12.52) months,respectively.Results The median time of underlying disease was 3.3 months (2 weeks to 6 months) in the CRVO patients and 11.1 months (4 to 36 mouths) in the DR patients,with a significant difference between them (Z =-2.40,P＜0.05).CRVO-derived NVG progress was much faster than that of DR-derived NVG.The number of the eyes with visual acuity improvement after treatment was 2 in the CRVO-derived NVG and 15 in the DR-derived NVG;while the number of the eyes with unchanged or worse visual acuity was 8 and 4 in the CRVO-derived NVG eyes and the DR-derived NVG eyes (x2 =9.38,P＜0.01).The difference of IOP in pre-and post-treatment was (37.00±9.91)mmHg in the CRVOderived NVG eyes and (8.92±12.05)mmHg in the DR-derived NVG eyes,showing a significant difference between them (t =6.30,P＜0.01).In the CRVO-derived NVG eyes,optic disc edema,retinal hemorrhage,and vein dilatation were seen in 6 eyes,and mild optic disc edema and retinal hemorrhage were observed in 4 eyes.After treatment,fundus could not be seen in 4 eyes,in other 2 eyes optic disc and retinal laser spots were unclearly observed.In addition,pale optic disc and retinal vessel occlusion appeared in 2 eyes,and silver wire-like arteries exhibited in 2 eyes.In pre-treated DR-derived NVG eyes,fundus could not be seen in 8 eyes and Ⅲ-Ⅳv stages of DR findings appeared in 11 eyes.After treatment,retinopathy was stabilized in 16 eyes of 15 cases.Advanced retinopathy(V-Ⅵ stages of DR findings) was revealed in 3 eyes of 3 cases.The incidence of the complication after treatment was 100.0％ in the CRVO-derived NVG eyes and 21.1％ in the DR-derived NVG eyes (x2=5.18,P＜0.05).Conclusions The clinical characteristics of NVG secondary to CRVO and DR are variable,an appropriate treatment option should be selected according to different features of NVG.