【作者】 姜荔；

【导师】 马志中；

【作者基本信息】 中国人民解放军军医进修学院 ， 眼科学， 2004， 博士

【摘要】 目的 以渗出型年龄相关性黄斑变性(AMD)为重点，从分析脉络膜新生血管(CNV)在光学相干断层成像(OCT)、眼底荧光造影(FA)和吲哚菁绿脉络膜造影上的特征入手，探讨与之相关的色素上皮(RPE)形态改变对疾病临床转归的影响。 资料和方法 1．描述2000年10月～2003年12月就诊于解放军总医院眼科的233例黄斑区CNV患者的概况：分析OCT在揭示与CNV相关的RPE形态学改变方面的优势。 2．选取做过OCT检查的渗出型AMD140人171只眼，应用Osiris医学图像分析软件测量其中存在色素上皮脱离(PED)的113只患眼的PED的角度、高度和基底直径，分析PED形态与RPE裂孔发生的关系。 3．选取所有做过OCT的黄斑区CNV患者，包括渗出型AMD 140人171只眼和非AMD62人74只眼，对比分析CNV类型及其相应的RPE形态学改变与黄斑囊样水肿(CME)的关系。 4．选取同期做过OCT和眼底造影检查的黄斑区CNV患者，包括渗出型AMD73人83只眼，非AMD37人40只眼，分析视网膜-脉络膜血管吻合(RCA)形成与PED的关系；再选取同期做过OCT和同步FA／ICGA检查的、处于病变活动期的渗出型AMD患者40人43只眼，分析其视网膜下新牛血管(SRN)的起源。 结果 1．黄斑区CNV患者中渗出型AMD占绝大多数(69.10％)，其余依次足中渗(17.60％)、病理性近视(8.15％)、脉络膜炎(3.86％)、脉络膜军医进修学院临床医学博士学位论文中文摘要裂伤(0.86%)和血管样纹(0.43%)。渗出型AMD患者以男性明显居多(>2:1)，男性患者的平均年龄显著高女性(尸二0.0013);渗出型AMD患眼PED的发生率(77.93%)显著高于非AMD的CNV患眼 (39.62%)，而且，其PED的高度和基底直径(0 .30士o.20mm和2.02士l.23mm)也显著高于非AMD的CNV患眼(0.21士0.lmm和0.99士0.34mm)。渗出型AMD患眼的PED裂孔最多见于PED的边缘(69.12%)，有裂孔发生的PED的角度和高度显著大于无裂孔者，而且以裂孔发生在边缘的PED的角度和高度更大。渗出型AMD患眼黄斑囊样水肿(CME)的发生率(52.05%)显著高于非AMD的CNV患眼(24.32%);处于AMD病变活动期的CME患眼多为结合型CNV(76.32%)和GassZ型CNV(18.42%)，而无CME的AMD患眼多为Gassl型CNV(82.61%)，统计学上差异显著 (P=0 .0000)。渗出型AMD患眼中45.33%有RCA形成，其中参与RCA形成的视网膜血管以小静脉居多;与无RCA患眼相比，PED裂孔明显多见于RCA患眼(分别为51 .52%和88.67%，尸二0.0030):AMD患眼的RCA发生率显著高于非AMD的CNV患眼(15%，尸荀.0010);RCA患眼新生血管复合体的主体起源于脉络膜。结论1.渗出型AMD患者男性居多与就诊人群中军人比例高相关，多数女性 患病较早可能与更年期后体内性激素水平失衡相关:OCT在早期发现 与CNV相关的RPE断面结构改变上具有优势。2.渗出型AMD患眼PED边缘裂孔的发生与PED的角度和高度呈正相 关，其中与角度的关系更为密切;OCT在早期发现和随访PED微裂军医进修学院临床医学博士学位论文中文摘要 孔方面具有优势。 3侵入视网膜感觉层下生长的CNV不断渗出、出血是导致黄斑囊样水 肿形成的直接原因。但是，与RPE断裂相关的外血一视网膜屏障破坏， 尤其是RPE细胞本身的功能减退可能是CNV最终能导致黄斑囊样水 肿形成且持续时间较长的根源。 4 RCA形成在临床上并不少见，尤其多见于渗出型AMD，虽然多与PED 并存，但是，两者之间无直接的因果关系;PED裂孔发生与RCA形 成密切相关，RPE细胞功能减退以及即E裂孔形成引起的视网膜感 觉层下色素上皮衍生因子(PEDF)与血管内皮生长因子(VEGF)比 例失衡很可能是RCA更多见于渗出型AMD的根本原因;视网膜血 管参与RCA形成可能只是一个继发的过程。更多还原

【Abstract】 ObjectivesTo analyze the effects of the morphological changes of retinal pigment epithelium (RPE) on the outcome of choroidal neovascularization (CNV), with highlight on exudative age-related macular degeneration (AMD), by means of evaluating the characteristics of CNV on optical coherence tomography (OCX), fluorecein angiography and indocyanine green angiography. Material and methods1. The general profile of 233 consecutive patients with CNV examined at the Ophthalmic Department of the PLA General Hospital between October 2000 and December 2003 was described. The advantages of OCT in disclosing the morphological changes of RPE associated with CNV were evaluated.2. One hundred and seventy-one eyes of 140 exudative AMD patients underwent OCT examination were selected, with 113 eyes presented with pigment epithelium detachment (PED). Osiris medical imaging software (version 4.18) was used to measure the angle, height and base diameter of PED. The relationship between the morphology of PED and the evolution of RPE tear was evaluated.3. Patients underwent OCT examination were all selected, including 171 eyes of 140 patients with exudative AMD and 74 eyes of 62 patients with CNV secondary to non-AMD. The correlation between the types of CNV, the morphological changes of RPE and the development of cystoid macular edema (CME) was analyzed.4. Patients underwent both OCT and fluorecein angiography (FA) examinations were selected, including 83 eyes of 73 patients with exudative AMD and 47 eyes of 40 patients with CNV secondary to non-AMD. The correlation between Retinal-Choroidal Anastomosis (RCA) and FED was evaluated. Forty-three eyes of 40 patients with active AMD lesions underwent OCT and simultaneous fluorescein and indocyanine green angiography (FA/ICGA) examinations were further investigated for the sources of subretinal neovascularization. Results1. The majority of patients with CNV were secondary to exudative AMD (69.10%); the minority was associated with CEC (17.60%), pathologic myopia (8.15%), choroiditis (3.86%), choroidal rupture (0.86%) and angiod streaks (0.43%) in descending order. Men with exudative AMD were more than two times as much as women, and the mean age of men was significantly older than women (P=0.0013). FED was much more common in exudative AMD than in non-AMD (77.93% versus 39.62%). The height and base diameter of FED associated with AMD (0.30 ± 0.20mm and 2.02±1.23mm) were significantly greater than that of non-AMD(0.21 ± 0.1 mm and 0.99 ± 0.34mm).2. FED tear associated with exudative AMD occurred more often at the edge (69.12%). Compared with FED without tear, FED with tear had significantly larger angle and higher height. FED with marginal tear showed even larger angle and higher height as compared with FED with non-marginal tear.3. The incidence of CME was significantly higher in exudative AMD than innon-AMD (52.05% versus 24.32%). In the active phase of exudative AMD, most of eyes with CME had either a combined CNV complex (76.32%) or a Gass 2 type CNV (18.42%), whereas, most of eyes without CME had Gass 1 type CNV (82.61%). The difference was statistically significant CP=0.0000).4. Forty-five point thirty-three percent of eyes with exudative AMD were found to have RCA; most of the anastomotic connection involved the retinal vein. Compared with eyes without RCA, FED tear was a more common sign in eyes with RCA (88.67% versus 51.52%, P=0.0030). The incidence of RCA formation was significantly higher in AMD than in non-AMD (45.33% versus 15%, P=0.0010). Eyes with RCA had their main portion of neovascular complex originated from choroid. Conclusions1. The higher proportion of old army men in this series was the reason for men with exudative AMD outnumbered women. It might be associated with imbalance of sex hormone after menopause for most women suffered from exudative AMD earlier than men. OCT is superior in visualizing the early structural changes of RPE associated with CNV.2. The occurrence of marginal FED tear associate更多还原