【作者】 吴葆健；

【导师】 魏素琴； 叶存喜；

【作者基本信息】 河北医科大学 ， 眼科学， 2004， 硕士

【摘要】 目的：1 视网膜中央静脉阻塞（CRVO）眼前段新生血管可以从虹膜瞳孔缘首先发生，也可以从房角首先发生，还可以虹膜和房角同时发生，其中房角新生血管由于缺乏对前房角镜检查的足够重视而易被漏诊，从而失去早期治疗的时机。目前对房角新生血管的发生率国内尚无人统计。本研究在于观察眼前段新生血管的发生情况，统计房角新生血管的发生比率，为今后临床上对缺血型CRVO患者应重视行前房角镜检查提供依据。2 全视网膜光凝术（PRP）治疗缺血型CRVO在临床上已得到广泛应用，但对光凝时机的选择尚有争议，有人主张行预防性PRP，有人主张发现眼前段新生血管后再行PRP。本研究通过观察PRP术后虹膜和房角新生血管的消退情况，为光凝时机的选择提供依据。3 彩色多普勒血流显像技术（CDFI）近年来已成为人们研究CRVO的一种重要手段，但尚未见有关激光后CRVO血流动力学变化的报道。本研究试图通过比较全视网膜光凝治疗前后CRVO球后血流动力学的变化，增强人们对于PRP治疗缺血型CRVO的认识。方法：1 根据视力、眼底表现及眼底荧光血管造影（FFA）检<WP=5>查的结果，将CRVO患者分为缺血型和非缺血型。非缺血型与缺血型CRVO的鉴别要点包括：（1）视力：非缺血型常轻度减退；而缺血型视力严重受损，常≤0.1。（2）眼底：非缺血型出血较少，静脉中度迂曲，视盘水肿；缺血型视网膜大量出血，静脉明显迂曲充盈，视盘水肿重，有棉絮斑。（3）FFA：非缺血型没有或仅有轻度毛细血管无灌注，也无新生血管；缺血型视网膜广泛的毛细血管无灌注，可见到新生血管。2 对病程6个月内的缺血型CRVO患者，在裂隙灯显微镜下每两周做一次前房角镜检查，仔细观察并记录有无虹膜或前房角新生血管发生及新生血管发生的范围。统计缺血型CRVO的发生率、眼前段新生血管的发生率及房角首先发生新生血管者的发生率。3 对于出现虹膜或房角新生血管的缺血型CRVO患者，行全视网膜光凝治疗，观察眼前段新生血管的消退情况，包括新生血管是否消退及消退的时间。4 利用CDFI分别于全视网膜光凝术前、术后检测缺血型CRVO患者的视网膜中央动脉（CRA）和视网膜中央静脉（CRV），记录CRA的管径（D）、收缩期峰值血流速度（PSV）、舒张末期血流速度（EDV）和阻力指数（RI），记录CRV的D和峰值血流速度（Vmax）。5 将全视网膜光凝前后视网膜中央静脉阻塞患者的球后血流动力学参数做配对对比研究。结果：1 共观察CRVO患者98例（98只眼）, 32例为缺血型（占32.65%），其中男性14例（43.75%），女性18例（56.25%），<WP=6>年龄52~76岁，平均65.84±5.77岁。首次就诊时病程6天~5个月, 平均64.27±37.70天。2 在32例缺血型CRVO患者中18例发生了眼前段的新生血管，占56.25%。发生时间为2.5~6个月, 高峰时间集中于3~4个月。其中虹膜先发生新生血管者10例（55.55%）；虹膜和房角同时新生血管者5例（27.78%）；房角先发生新生血管者3例（16.67%）。3 将虹膜和房角分为上方、下方、鼻侧、颞侧四个象限。虹膜新生血管10例中：上方6例（60%），颞侧2例（20%），鼻侧1例（10%），上方和颞侧1例（10%）。房角新生血管3例中：上方2例（66.67%），颞侧1例（33.3%）。在5例虹膜和房角同时发生新生血管的患者中：虹膜四个象限新生血管、房角上方和颞侧新生血管1例；虹膜上方、鼻侧和颞侧新生血管、房角上方新生血管1例；虹膜上方和颞侧新生血管、房角上方新生血管2例；虹膜上方新生血管、房角下方和颞侧新生血管1例。4 在18例虹膜和房角新生血管中，经PRP治疗后，新生血管未消退1例（5.6%），后因眼压升高住院手术治疗；其余17例（94.4%）新生血管最终完全消退，新生血管最早的于第３天开始部分消退，完全消退时间为5~35天，平均12.47±7.04天。5 CRA血流动力学参数PRP术前D为0.85±0.15mm，PSV为8.59±2.81cm/s，EDV为2.19±0.73cm/s，RI为0.73±0.09。PRP术后D为0.82±0.13mm，PSV为7.66±1.85cm/s，EDV为2.05±<WP=7>0.64cm/s，RI为0.70±0.08。PRP术后PSV、RI较术前降低，差异有显著性意义（P<0.05）。PRP术后D、EDV和术前比较有降低的趋势，但结果无显著性差异（P>0.05）。6 CRV血流动力学参数PRP术前D为0.79±0.20mm，Vmax为4.72±1.47cm/s。PRP术后D为0.78±0.12mm，Vmax为4.70±1.40cm/s。PRP术前、术后各参数比较有降低趋势，但结果无显著性差异（P>0.05）。结论：1 缺血型CRVO引起的早期眼前段新生血管可以表现为三种形式：虹膜新生血管、虹膜和房角同时新生血管以及房角新生血管。本研究统计房角首先发生新生血管者约占16.67%，为了防止这部分病人漏诊，应加强前房角镜检查。2 眼前段新生血管以上方象限发生较多，具体原因不详，但却提醒我们在行前房角镜检查时要特别注意上方瞳孔缘与上方房角的检查。3 虹膜新生血管发生后，一旦范围超过两个象限，发生房角新生血管的机率较大，因此对于范围超过180度的虹膜新生血管，更应注重前房角镜检查。4 PRP治疗缺血型CRVO，可有效的使虹膜或房角新生血管消退，有效率高达94.4%。同时考虑到并非所有的缺血型CRVO都产生虹膜或房角新生血管（本研究中的发生率更多还原

【Abstract】 Objectives:1 The anterior segment neovascularization (NV) of central retinal vein occlusion (CRVO) generated firstly either from the pupillary margin of iris or from the angle of anterior chamber, yet there was no statistics about it in domestic. The angle neovascularization (ANV) was often missed diagnosis because of our lack of paying sufficient attention to gonioscopy, thus the best time of early treatment may be loss. Our study was to observe the occurrence of anterior segment NV and statistics the incidence of ANV, through which to provide theory evidence to pay sufficient attention to gonioscopy for ischemic CRVO patients.2 Panretinal photocoagulation (PRP) had been widely used in the treatment of ischemic CRVO，but there was still dissension on the time of performing PRP. Our study wanted to observe the extinction of NV in ischemic CRVO patients after PRP, and to provide evidence for choosing the time of performing PRP.3 Color Doppler flow imaging (CDFI) was an important mean of studying CRVO, yet there was no report about it after PRP. Through the study of this problem, we try to reinforce our <WP=10>cognition about CRVO and PRP.Methods:1 According to sight, fundus manifestation and FFA, CRVO patients were divided into two types: ischemic CRVO and non-ischemic CRVO. The features of ischemic CRVO identified from non-ischemic CRVO included: (1) Visual acuity: Ischemic CRVO decreased severely and usually less than 0.1, while non-ischemic CRVO decreased slightly. (2) Fundus manifestation: The hemorrhage was more, the distortion of vein was clearer, the papilloedema was more serious in ischemic CRVO than non-ischemic CRVO. Multiple cotton-wool spots could be seen in ischemic CRVO. (3) FFA: Ischemic CRVO had retinal capillary nonperfusion widely and NV, while non-ischemic CRVO had little retinal capillary nonperfusion and no NV.2 The iris and anterior chamber angle of each ischemic CRVO patient, whose course was less than six months, were examined carefully under slit lamp every two weeks, and record the occurrence of NV. 3 Treat the ischemic CRVO patients with PRP when INV/ANV occurred, and observe the extinction of NV.4 CDFI was used to quantitate diameter (D), peak systolic velocity (PSV), end diastolic velocity (EDV) and resistance index (RI) of the central retinal artery (CRA) in ischemic CRVO patients before and after PRP; and to quantitate diameter (D) and maximum velocity (Vmax) of the central retinal vein <WP=11>(CRV). 5 The statistical comparison of the hemodynamic parameters before and after PRP was performed by paired-t test.Results:1 Among the 98 CRVO patients, there were 32 ischemic patients, including 14 men and 18 women. The ages of the 32 patients was from 52 to 76, mean 65.84±5.77. The courses of CRVO were from 6 days to 5 months, mean 64.27±37.70 days.2 Among 32 ischemic CRVO, 18(56.25%) occurred anterior segment NV. The time of occurrence was 2.5~6 months, mainly from 3 to 4 months. Among 18 anterior segment NV, 10(55.55%) occurred firstly from iris, 3(16.67%) occurred firstly from angle, and 5(27.78%) occurred simultaneously from iris and angle.3 The iris and angle were divided into four quadrants: superior, inferior, nasal and temporal. In 10 INV, there were 6 (60%) in superior quadrant, 2(20%) in temporal quadrant, 1 (10%) in nasal quadrant, 1(10%) in superior and temporal quadrant. In three ANV, there were 2(66.7%) in superior quadrant, 1(33.3%) in temporal quadrant.There were 5 patients occurred anterior segment NV simultaneously in iris and angle: One was in four quadrants iris and in superior and temporal angle; One was in superior、nasal and temporal iris and in superior angle; Two was in superior and temporal iris and superior angle; One was in superior iris and in <WP=12>inferior and temporal angle.4 NV didn’t disappear only in one patient after PRP among 18 patients occurred INV/ANV, and in the rest 17(94.4%), NV regressed completely. NV began to regress at the 3rd day after PRP, and the time NV completely regressed was from 5 to 35 days,更多还原