目的 分析儿童急性淋巴细胞白血病化疗术后合并巨细胞病毒性视网膜炎的临床特点及诊疗预后.方法 分析2014年7月至2017年9月确诊的急性淋巴细胞白血病合并巨细胞病毒性视网膜炎的患者17例(30眼)的实验室检查和临床诊治资料,分析巨细胞病毒性视网膜炎发病的危险因素、治疗方法和预后.所有患者给予详细的眼部检查,包括裂隙灯显微镜检查、散瞳眼底检查及彩色眼底照相.全身检查包括血CMV-DNA、尿CMV-DNA及眼底病变发现时和病变进展或静止时的CD4+T细胞计数.巨细胞病毒性视网膜炎一经发现即给予全身抗病毒治疗,对于全身治疗不耐受、不良反应明显或病变持续进展的患者给予玻璃体腔注射抗病毒药物.结果 确诊为巨细胞病毒性视网膜炎的急性淋巴细胞白血病患者17例30眼,男8例(14眼),女9例(16眼);年龄5～14岁,平均年龄(8.18±2.64)岁.76.5％的患者病变累及双眼,23.5％的患者为单眼发病,其中13.3％为中心型病变,36.7％为周边型病变,50％为混合型病变,且30％累及黄斑;20％合并视神经炎,40％表现为广泛视网膜血管炎.发病时CD4+T淋巴细胞计数为20～186个/μl,平均(99.66±49.1)个/μl,其中17.6％的患者CD4+T淋巴细胞计数<50个/μl,17.6％的患者为50～100个/μl,52.9％的患者为100～150个/μl,11.8％的患者>150个/μl.9例患者经更昔洛韦全身治疗后视网膜病变逐渐静止消退,6例患者经全身抗病毒治疗后活动性病变无减少或仍有进展,给予玻璃体腔局部注射更昔洛韦,治疗后病变均静止.2例患者未规律接受全身抗病毒治疗并发视网膜脱离.结论 巨细胞病毒性视网膜炎一经发现以全身抗病毒治疗为主,同时检测细胞免疫功能,随着免疫功能的提高治疗可取得较好的效果,对于全身治疗不能耐受、不良反应明显或治疗效果不佳的患者可行玻璃体腔注射抗病毒药物以控制疾病的进展.%Objective To investigate the clinical features, treatment and prognosis of children patients with acute lymphoblastic leukemia complicated by cytomegalovirus retinitis after chemotherapy. Methods The clinical data about 17 patients (30 eyes) with acute lymphoblastic leukemia complicated by cytomegalovirus retinitis after chemotherapy who were treated in our hospital from January 2014 to September 2017 were collected to analyze retrospectively the risk factors of pathogenesis of cytomegalovirus retinitis, therapeutic method and prognosis of patients. All the patients underwent slit-lamp ophthalmoscopy, mydriasis fundus examination, color fundus photography and general physical examination including blood CMV-DNA,urine CMV-DNA and CD4+T lymphocyte counts. The patients were once suffered from cytomegalovirus retinitis, they were given systemic antiviral treatment,however, the patients who were intolerant to systemic antiviral treatment and had obvious adverse reactions or continuing progression of lesions were given antiviral drugs by intravitreal injection. Results Among 17 patients (30 eyes) with acute lymphoblastic leukemia who were diagnosed definitely as cytomegalovirus retinitis, there were 8 males (14 eyes),9 females (16 eyes),with age ranges being 5～14 tears [mean age (8. 18 ± 2. 64)years]. The lesions in 76. 5％ of patients were involved in binoculus,and 23. 5％ of patients with unilateral disease,and 13. 3％ of them were central lesions,36. 7％ were peripheral lesions,50％ were mixed lesions,30％ were involved in yellow spot,20％ were combined with optic neuritis and 40％ were with extensive retinal vasculitis. The CD4+ T lymphocyte counts were 20 ～186 cells/μl,with mean counts being (99. 66 ± 49. 1)cells/μl,which in 17. 6％ of patients were less than 50 cells/μl,17. 6％ of patients were 50～100 cells/μl,52. 9％ of patients were 100～150 cells/μl,11. 8％ of patients were more than 150 cells/μl. Moreover the retinopathy was gradually subsided in 9 patients after systemic treatment, however, the active lesion was not relieved in 6 patients after systemic antiviral therapy treatment, then the 6 patients were given ganciclovir by intravitreal injection untill the pathological changes were stopped. In addition 2 patients who did nor receive regular systemic antiviral therapy suffered from retinal detachment. Conclusion Once incidence of cytomegalovirus retinitis, the patients should be treated by systemic antiviral drugs,at the same time,cell immune function of patients should be detected. For the patients whoare intolerant to systemic treatment,with obvious adverse reactions or progression of lesions, can be treated by giving antiviral drugs through intravitreal injection to control the progression of diseases.
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