抗血管内皮生长因子单克隆抗体bevacizumab治疗渗出型老年性黄斑变性疗效观察及无效病例分析

摘要

目的 观察玻璃体腔注射抗血管内皮生长因子单克隆抗体bevacizumab(IVB)治疗渗出型老年性黄斑变性(AMD)的效果,分析治疗无效的原因.方法 开放性、单一治疗组的前瞻性研究.经最佳矫正视力(BCVA)、荧光素眼底血管造影(FFA)、吲哚青绿血管造影(ICGA)及光相干断层扫描(OCT)检查确诊为渗出型AMD的17例患者18只眼纳入研究.确诊并取得患者知情同意后行第1次IVB治疗.此后第6、12、24、36、48周分别行第2、3、4、5、6次IVB治疗.治疗前及每次治疗后均行BCVA、眼压、裂隙灯显微镜、眼底、彩色眼底照相、OCT检查,于治疗前及第6、24、52周行FFA和ICGA检查.以末次随访患者BCVA所见字母数增加、不变或减少＜5个为治疗有效,字母数减少≥5个为治疗无效；观察其治疗效果.对比分析治疗无效患眼治疗前后OCT测得的黄斑中心凹视网膜厚度(CMT)、病变最大处视网膜厚度( MRT)变化以及FFA和ICGA的形态学变化情况.结果 18只眼中,有效12只眼,占66.67％；无效6只眼,占33.33％.无效眼治疗前平均CMT、MRT为506.83、635.33μtm,治疗后平均CMT、MRT为446.17、563.67 μm;治疗后较治疗前分别降低了60.67、71.67 μm,差异均无统计学意义(t=-1.572,-0.943；P=0.116,0.345).FFA及ICGA检查发现,治疗无效的6只眼中,3只眼病灶位于黄斑中心凹区域内,整个治疗过程中未见病灶反复活动,第6次治疗后病灶均出现大片状瘢痕化.另3只眼在第3次治疗后黄斑区病灶面积扩大,荧光渗漏,CNV呈花环样；第6次治疗后,黄斑区荧光渗漏较第3次治疗后减轻,部分病灶瘢痕化.OCT检查发现,治疗无效眼神经上皮脱离减轻,视网膜色素上皮与脉络膜光带较治疗前光滑,但仍有增厚、隆起,黄斑区视网膜水肿.结论 IVB治疗渗出型AMD具有一定的有效性.治疗无效的原因可能与CNV活动性强、病灶范围扩大以及病灶位于黄斑中心凹区域内有关.%Objective To observe the effect of intravitreal bevacizumab (IVB) for exudative agerelated macular degeneration (eAMD),and analyze the reasons for treatment failure.Methods Eighteen eyes of 17 patients with eAMD who have been diagnosed by fundus fluorescein angiography (FFA),indocyanine green angiography (ICGA) and optical coherence tomography (OCT) were enrolled in this openlabel,single treatment group and prospective study.The patients received the first IVB treatment after diagnosis,and received the 2nd,3rd,4th,5th and 6th IVB treatment at 6,12,24,36,48 weeks after the first injection.The examinations of best corrected visual acuity (BCVA),intraocular pressure,slit lamp microscope,fundus photography,FFA,ICGA and OCT were performed before and after treatment.Nonresponders were defined as patients who had BCVA loss more than 5 letters at week 52 compared with BCVA before treatment.The therapeutic effects of IVB for eAMD were observed.The central macular thickness (CMT),maximum retinal thickness (MRT) and morphological changes of FFA,ICGA and OCT before and after treatment were comparative analyzed.Results Of the 18 eyes,12 eyes (66.67％) were effective to IVB,6 eyes (33.33％) were non-responders.The average CMT and MRT of non-responders were 506.83,635.33 μm before treatment,which decreased to 446.17,563.67 μtm at 52 weeks.They were reduced by 60.67 and 71.67 μtm respectively,but there was no statistically significant differences (t =-1.572,-0.943; P=0.116,0.345).FFA and ICGA examination found that the CNV lesions of 3 nonresponder eyes located in the foveal region,and became scars after the 6th treatment.The other 3 nonresponder eyes developed CNV repeatedly during the treatments,and after the 6th injections of bevacizumab the lesions were under control with less fluorescein leakage and macular retinal edema.Conclusion IVB treatment is effectivefor some eAMD patients,but is ineffective for patients with extensive expanded CNV and foveal CNV.