息肉状脉络膜血管病变的临床特征、治疗与基因多态性研究

【作者】 王静；

【导师】 陈有信；

【作者基本信息】 北京协和医学院 ， 眼科学（专业学位）， 2014， 博士

【摘要】 第一部分息肉状脉络膜血管病变单核苷酸多态性的初步研究目的：探讨LOC387715/HTRA1、PEDF、ELN、TIMP3、LIPC、CETP基因的多态性与中国人群息肉状脉络膜血管病变的相关性。方法：本研究采用病例-对照关联分析的方法。共纳入没有亲缘关系的153名PCV患者和与之年龄和性别相匹配的221名正常对照者。提取所有受试者全血DNA。采用MassAFRAY时间飞行质谱技术完成对所有SNP位点的基因型检测,基因型分布符合Hardy-Weinberg平衡。使用x2检验分析两组间的等位基因频率和基因型频率,同时对多重比较进行Bonferroni校正,所有统计学分析在SPSS17.0软件下进行。采用Haploview软件分析连锁不平衡区块和基于连锁不平衡的单体型。结果：LOC387715/HTRA1(rs10490924、rs3793917、rs11200638)的等位基因频率在PCV组和正常对照组比较上具有统计学差异(P=3.46×10-10、3.40×10-9、8.31×10-11),经Bonferroni进行多重检验校正,仍具有统计学意义。LOC387715/HTRA1(rs10490924、rs3793917、rsl1200638)的基因型频率在两组之间比较也具有统计学意义(P=8.926×10-9、3.408×10-8、1.099×10-9),通过Logistic回归控制年龄和性别后比较其仍有统计学意义。LOC387715/HTRA1(rs10490924、rs3793917、rs11200638)三个位点之间互相高度连锁(r2=0.95、0.89、0.85),对这个高度连锁区域进行单体型相关性的分析发现,rs10490924、rs3793917和rs11200638的TCA型和GGG型在PCV组与对照组间比较具有统计学差异(P=1.80×10-9、1.92×10-10)。PEDF (rsl136287)、ELN (rs2301995). TIMP3(rs8136803、rs2283883、rs242089. rs1962223、rs242082、rs80272、rs135025、rs715572、rs242076)、LIPC (rs6078. rs6083、rs1800588、rs3829462、rs1077834)、CETP(rs4783961、rs1800775、rsl7245715、 rs1801706、rs5882)的等位基因频率和基因型分布在PCV组与对照组比较均无统计学意义(P>0.05)。而对TIMP3、LIPC、CETP基因进行连锁不平衡和基于连锁不平衡的单体型分析,结果显示在PCV组与对照组比较也无统计学意义(P>0.05)。结论：本研究结果显示PEDF、ELN、TIMP3、LIPC、CETP基因的多态性与中国人群PCV无明显相关性；证实了LOC387715/HTRA (rs10490924、rs3793917、rs11200638)与中国人群PCV发病的显著相关。第二部分息肉状脉络膜血管病变的临床特征分析目的：观察息肉样脉络膜血管病变(PCV)的临床特征及寻找其发生和发展的相关危险因素。方法：回顾性、非对照性病例系列研究。临床确诊为PCV的153例患者185只眼纳入研究。对所有患者进行标准问卷调查并分析临床资料。调查的内容包括性别、年龄、职业、是否有高血压、糖尿病、高血脂、冠心病病史,吸烟、饮食习惯,身高、体重等。所有患者均行最佳矫正视力、裂隙灯显微镜、间接检眼镜、眼底彩色照像、荧光素眼底血管造影、吲哚青绿血管造影以及光相干断层扫描检查。结果：153例患者中,男性82例,占53.59%;女性71例,占46.41%。年龄44-84岁,平均年龄(64.94±9.49)岁。体重指数15.82-32.19,平均为(24.74±2.37)。有高血压病史51例,占33.33%；有高血脂病史73例,占47.71%；有吸烟史48例,占31.37%。双眼发病32例,占20.92%；单眼121例,占79.08%。121例单眼PCV患者中,另眼可见玻璃膜疣39例,占32.23%；有玻璃体积血的30只眼,占16.22%。有5例患者曾有中心性浆液性视网膜脉络膜病变(CSC)病史,占3.27%。PCV病变位于黄斑区123只眼,占66.49%：位于血管弓区23只眼,占12.43%；视盘旁8只眼,占4.32%。息肉状病灶表现为孤立状72只眼,占38.91%；簇状96只眼,占51.89%；串样2只眼,占1.08%；分支状3只眼,占1.62%；既有孤立状同时也有簇状12只眼,占6.49%。存在神经视网膜下液性暗区108只眼,占58.38%；出血性RPE脱离94只眼,占50.81%；浆液性RPE脱离22只眼,占11.89%。结论：PCV患者双眼发病率高,女性患病比例较高,浆液性或出血性PED发生率较高,PCV病灶主要位于黄斑区。年龄和种族因素可能是PCV最主要的危险因素,吸烟、高血压、高血脂可能与PCV发生有一定联系。第三部分光动力疗法与玻璃体腔注射抗血管内皮生长因子制剂治疗息肉样脉络膜血管病变的系统评价目的：系统评价单纯光动力疗法(PDT)或单纯玻璃体腔注射抗血管内皮生长因子制剂疗法(VEGF)或PDT联合玻璃体腔注射抗VEGF制剂治疗息肉样脉络膜血管病变(PCV)的有效性。方法：全面检索Pubmed、Biosis Preview、Cochrane Library, Embase数据库有关PDT、抗VEGF治疗PCV的文献,按纳入和排除标准确定入选文献并根据设计方法分类。利用比较性研究对抗VEGF与PDT、抗VEGF与联合治疗、PDT与联合治疗进行荟萃分析和两两比较,主要终点为息肉样病灶的消退率,其它终点包括最佳矫正视力(BCVA)、黄斑中心凹视网膜厚度(CRT)、治疗次数等指标。结果：共得到比较性临床试验13项,其中随机对照试验(RCT)1项,回顾性比较研究(RCS)12项,对上述3个治疗方案进行了两两比较；有4项研究对单纯抗VEGF和单纯PDT进行了比较,7项研究对单纯PDT和联合治疗进行了比较,4项研究对单纯抗VEGF和联合治疗进行了比较。综合考虑RCT及RCS结果：单纯PDT与单纯抗VEGF相比,6个月时病灶消退率更高(P=0.0037),而BCVA、CRT在12个月随访范围内差异无统计学意义；单纯PDT和联合治疗相比,虽然12个月时病灶消退率、BCVA、CRT的差异无统计学意义,但在24个月时联合治疗组BCVA倾向于具有更好的视力(P=0.05),且联合治疗组所需PDT次数有所减少；联合治疗和单纯抗VEGF相比,12个月时病灶消退率显著增高,所需眼内注射次数较少,而BCVA、CRT的差异无统计学意义。结论：单纯玻璃体腔注射抗VEGF制剂治疗在促进病灶消退方面不及单纯PDT或PDT联合玻璃体腔注射抗VEGF制剂治疗,联合治疗的远期(2年)视力可能优于单纯PDT。第四部分光动力疗法治疗息肉状脉络膜血管病变随访三年效果观察目的：观察光动力疗法(PDT)治疗息肉状脉络膜血管病变(PCV)随访3年的治疗效果。方法：回顾性、非对照性病例系列研究。临床确诊为PCV的29例患者32只眼纳入研究。所有患者首次均行常规PDT治疗。对治疗后6个月有活动性息肉状病灶、病灶残留及渗出性改变者,行PDT联合玻璃体注射抗血管内皮生长因子(VEGF)制剂治疗或单纯玻璃体注射抗VEGF制剂治疗。所有患者均随访3年以上,平均随访时间(43.64+10.84)个月。观察统计患者首次PDT治疗后1、3、6、12、24、36个月的最佳矫正视力(BCVA)以及随访期间的PCV复发率和治疗次数。BCVA转换为最小分辨角对数(logMAR)视力记录和分析。结果：首次PDT治疗后1、3、6、12个月,患者平均BCVA均较治疗前明显提高,差异有统计学意义(t=2.27、4.57、3.77、2.37,P<0.05)。首次PDT治疗后24、36个月,患者平均BCVA较治疗)前有所下降,但差异无统计学意义(t=-1.29、-0.81,P>0.05)。首次PDT治疗后36个月,视力提高6只眼,占所有患眼的18.75%；视力稳定14只眼,占所有患眼的43.75%；视力下降12只眼,占所有患眼的37.50%。随访期间,PCV复发24只眼,占所有患眼的75.00%；未复发8只眼,占所有患眼的25.00%。PCV复发的24只眼中,1次复发12只眼,占复发患眼的50.00%；2次复发9只眼,古复发患眼的37.50%；3次复发3只眼,占复发患眼的12.50%。首次PDT治疗后12个月内复发4只眼,占复发患眼的16.67%；治疗后13～24个月复发11只眼,占复发患眼的45.83%；治疗后25～36个月复发9只眼,占复发患眼的37.50%。所有患者PDT治疗、抗VEGF治疗平均次数分别为(1.86±1.04)、(4.95±3.92)次。结论：PDT治疗PCV随访3年的治疗效果较差,其视力提高率较低,PCV复发率较高。更多还原

【Abstract】 Part I A preliminary study on single nucleotide polymorphisms of polypoidal choroidal vasculopathy patientsPurpose:To investigate whether polymorphisms in the LOC387715/HTRA1, PEDF, ELN, TIMP3, LIPC and CETP genes are associated with polypoidal choroidal vasculopathy(PCV)in a Chinese population.Methods:A case-control association study of153unrelated Chinese patients with PCV and221control subjects matched in ethnicity and gender was undertaken. Genomic DNA was prepared from peripheral blood. All SNPs were genotyped using the MassArray platform and MALDI-TOF analysis. Genotypic distribution was tested for Hardy-Weinberg equilibrium. Statistical analyses were performed on computer using the SPSS (version170:SPSS Science, Chicago, IL) software. The genotype and allele frequencies were evaluated using the x2tests. Bonferroni corrections for multiple comparisons were performed. The significance of the differences in the estimated haplotype frequencies between case and control groups were examined on Haploview4.2using the x2tests.Results:Three SNPs for LOC387715/HTRA1, rs10490924, rs3793917and rs11200638, showed significant differences in allele frequencies between PCV and control groups (P=3.46×10-10,3.40×10-9,8.31×10-11, respectively). The significant differences remained after Bonferroni correction. The genotype frequencies of rs10490924, rs3793917and rs11200638in LOC387715/HTRA1were also found to be significantly different between PCV and control groups(P=8.926X10-9,3.408X10-8,1.099X10-9, respectively). The differences for rs10490924, rs3793917and rs11200638were still significant among the PCV cases after adjustment for age. Three SNPs for LOC387715/HTRA1, rs10490924, rs3793917and rs11200638, showed high linkage (r2=0.95,0.89,0.85, respectively). The haplotypes TC A and GGG of rs10490924, rs3793917and rs11200638were also associated with PCV (P=1.80X10-9,1.92X10-10, respectively). No significant association was noted with PEDF (rs1136287), ELN (rs2301995), TIMP3(rs8136803, rs2283883, rs242089, rs1962223, rs242082, rs80272,rs135025,rs715572,rs242076),LIPC(rs6078,rs6083,rs1800588,rs3829462, rs1077834), CETP (rs4783961, rs1800775, rs17245715, rs1801706, rs5882) among the PCV cases(P>0.05). Evaluation of common haplotypes across TIMP3, LIPC and CETP did not reveal any association with PCV(P>0.05).Conclusions:We found no evidence to support the polymorphisms of PEDF、ELN、 TIMP3、LIPC and CETP in the susceptibility to PCV in a Chinese population. The SNPs rs10490924, rs3793917and rs11200638of LOC387715/HTRA1are significantly associated with the risk of PCV. Part II Clinical characteristics of polypoidal choroidal vasculopathyObjective:To observe the clinical characteristics of polypoidal choroidal vasculopathy (PCV) and to explore the possible risk factors associated with the development and progression of PCV.Methods:This is a retrospective, uncontrolled case series study. One hundreds fifty-three PCV patients(185eyes)were enrolled in this study. All the patients were underwent stardard questionnaire survey by one trained person. Uniform questionnaires were administered to obtain information such as gender, age, occupation, hypertension, diabetes, hyperlipemia, coronary heart disease, smoking, diet, height, and weight etc. All the patients were examined for best corrected visual acuity(BCVA)testing, slit—lamp microscope, indirect ophthalmoscopy, fundus photography, fluorescein angiography, indocyanine green angiography and optic coherence tomography.Results:The patients included82males(53.59%)and71females(46.41%); the age was from44to84years, with a mean age of(64.94±9.49)years. The body mass index(BMI) was from15.82to32.19, with a mean BMI of (24.74±2.37). There were fifty-one patients with a history of hypertension(33.33%), seventy-three patients with a history of hyperlipemia (47.71%), and fourty-eight patients with a history of smoking (31.37%). Bilateral lesions were observed in32patients(20.92%)and unilateral lesions were observed in121patients(79.08%). In121patients with unilateral PCV lesions, drusen can be observed in the contralateral eyes of39patients(32.23%), Vitreous hemorrhage was observed in30eyes(16.22%).There were five patients with a histoty of central serous chorioretinopathy(3.27%). PCV lesions located at macula area in123eyes(66.49%), under the temporal retinal vascular arcade in23eyes(12.43%), and peripapillary in8eyes(4.32%). PCV lesion formation was single in72eyes(38.91%), cluster in96eyes (51.89%), string in2eyes(1.08%), branch in3eyes(1.62%), and both single and cluster polyps in12eyes(6.49%). There were108eyes(58.38%)with sub-neuroretinal fluid,94eyes(50.81%)with hemorrhagic pigment epithelium detachment, and22eyes(11.89%)with serous pigment epithelium detachment.Conclusion:PCV patients have higher bilateral incidence and female prevalence, higher serous or hemorrhagic PED incidence, and higher rate of macula area lesions. Age and race factor may be the most important risk factor for PCV, smoking, hypertension, and hyperlipemia may have some contact with PCV. Part Ⅲ Efficacy evaluation of photodynamic therapy and intravitreal anti-vegf injection for polypoidal choroidal vasculopathy:systematic reviewObjectives:To compare the efficacy of photodynamic therapy (PDT) alone, intravitreal anti-vascular endothelial growth factor (VEGF) therapy alone, and the combination of the two therapies for polypoid choroidal vasculopathy (PCV).Methods:A computerized search was conducted in Pubmed, Biosis Preview, Cochrane Library, and Embase. Studies comparing any two of the above three treatment strategies were enrolled in the study. Meta-analysis of pairwise comparisons of the three approaches were conducted. The primary endpoint was the proportion of patients with complete regression of polyps. Other endpoints included best corrected visual acuity(BCVA), central retinal thickness(CRT), number of treatments.Results:A total of13comparative studies were obtained, including1randomized controlled trials (RCT) and12retrospective comparative study (RCS). Four studies compared anti-VEGF monotherapy with PDT monotherapy. Seven studies compared PDT monotherapy with combination therapy. Four studies compared anti-VEGF monotherapy with combination therapy. Considering the RCT and RCS results:PDT was superior to anti-VEGF in achieving complete regression of polyps at month6(P=0.0037), although BCVA and CRT showed no significant difference at12-month follow-up. There was no significant difference in BCVA, CRT, and the proportion of patients with complete regression of polyps between PDT and combination group at12months follow-up. However, combination therapy showed more promising result in improving visual acuity at24months (P=0.05), with fewer PDT needed than in PDT monotherapy.Combination therapy was superior to anti-VEGF in achieving complete regression of polyps and the number of injections needed tended to be fewer.BCVA improvement and CRT reduction showed no significant difference at12-month follow-up.Conclusions:PDT with or without anti-VEGF therapy is superior to anti-VEGF monotherapy in achieving complete polyp regression, and combination therapy appeared toresult in better visual outcome than PDT monotherapy in the long term(2years). PartⅣ Three-year follow-up results of photodynamic therapy for polypoidal choroidal vasculopathyObjective:To evaluate the3-year efficacy of photodynamic therapy (PDT) in patients with polypoidal choroidal vasculopathy (PCV).Method:This is a retrospective, uncontrolled case series study. Thirty-two eyes of29patients wih PCV were enrolled. All patients were primarily treated with the first conventional PDT. For the eye with active polypoida, residual or exudative lesions in6month after PDT, PDT combined with intravitreal anti vascular endothelial growth factor (VEGF) or simple vitreous injection of anti VEGF therapy were used. All the patients were followed up for at least3years with the mean follow-up duration of43.64±10.84months. The best-corrected visual acuity (BCVA) in1,3,6,12,24and36months after the primary PDT, PCV recurrence rates and number of treatments were followed and analyed. The BCVA was converted into a logarithm of the minimal angle of resolution (logMAR) for statistical analysis.Results:During the1,3,6,12months after the primary PDT, the mean BCVA were all improved with statistically significant difference (t=2.27,4.57,3.77,2.37; P<0.05). During the24and36months after PDT, the mean BCVA was decreased without statistically significant difference (t=-1.29,-0.81;P>0.05). On the final evaluation at36months, the mean BCVA was improved in6eyes (18.75%), stable in14eyes (43.75%), and decreased in12eyes (37.50%). During the follow-up time, recurrence of PCV in24eyes (75.00%), no recurrence in8eyes (25.00%). There was1recurrence in12eyes(50.00%),2recurrences in9eyes(37.50%),3recurrences in3eyes(12.50%). Initial recurrences were noted in4eyes (16.67%) within12months of baseline PDT treatment; in11eyes (45.83%) between13and24months; in9eyes (37.50%) between25and36months. The mean number of PDT and anti-VEGF was1.86±1.04and4.95±3.92in all patients, respectively.Conclusions:The3-year efficacy of PDT in patients with PCV was poor with low improvement of visual acuity and high recurrence rate of PCV.更多还原