【摘要】  目的  探讨获得性免疫缺陷综合征(acquired immunodeficiency syndrome, AIDS)并发巨细胞病毒性(cytomegalovirus, CMV) 视网膜炎的眼底表现特点，全身症状及治疗预后。 

    方法  观察分析AIDS并发CMV视网膜炎15只眼（8例患者），对其眼底表现、视力、眼底荧光血管造影及CD4+T淋巴细胞进行了2～34个月，平均16个月的观察。分别对其中4只眼（2例患者）施行了“更昔洛韦玻璃体腔注药术”。

    结果  15只眼初诊视力：£ 0.2 10只眼（66.7%），（无光感2只眼，眼前光感2只眼，0.04～0.2 6只眼）。0.8和0.9 各1只眼（13.3%）。³ 1.0 3只眼（20%）。12只眼眼底表现为视网膜血管炎，沿血管分布的浓厚黄白色病损，其上片状出血及边缘不规则的黄白色颗粒。可形象地描述为“奶酪加番茄酱视网膜炎”。玻璃体透明或反应轻微。2只眼眼底为晚期表现，视网膜萎缩呈灰色，视网膜血管硬化、狭窄，视网膜色素上皮萎缩透见脉络膜血管及视神经萎缩。1只眼视网膜脱离。CD4+T淋巴细胞计数在0～36/mm3之间，平均15.0±12.9/mm3。4只眼玻璃体腔注药术后视力均有显著提高。眼底病变显著消退，出血吸收。  结论  CMV视网膜炎是AIDS最常见、最严重的眼部并发症。眼底表现特点为进行性、坏死性视网膜炎伴出血，同时合并有视网膜血管炎。但玻璃体反应无或轻微。对原因不明的黄白色病损，视网膜出血及视网膜血管炎，应作血清人类免疫缺陷病毒(human immunodeficiency virus, HIV) 抗体检测。反之，HIV阳性者应常规进行眼底检查。

    【关键词】  巨细胞病毒性视网膜炎； 获得性免疫缺陷综合征

Cytomegalovirus retinitis associated with Acquired immunodeficiency syndrome  YE Jun-jie*, LI Hai-yan, SUN Ding, MIN Han-yi, HAN Bao-ling, HU Tian-sheng.*Department of Ophthalmology, Peking Union Medical College Hospital, Eye Research Center, Chinese Academy of Medical Sciences, Beijing  100730, ChinaCorresponding author: YE Jun-jie, Email: [email protected]

【Abstract】  Objective  To investigate the fundus characteristics, systemic features and

     therapeutic outcomes of cytomegalovirus (CMV) retinitis associated with acquired immunodeficiency syndrome (AIDS).  Methods  Fundus features, Visual acuity, fluorescence fundus angiography (FFA) and CD4+T-lymphocyte counts of 15 eyes (8 patients) of CMV retinitis associated with AIDS were observed and analyzed. Follow-up at 16 months on average (2~34 months). Intravitreal ganciclovir (400mg) injection was performed for the 4 eyes (2 patients).  Results  In the initial examination, the visual acuity in the 15 eyes were：£ 0.2 in the 10 eyes (66.7%), (no light perception (NLP) in the 2 eyes, light perception (LP) in the 2 eyes, 0.04 ~ 0.2 in the 6 eyes). 0.8 and 0.9 in the 1 respective eye (13.3%). ³ 1.0 in the 3 eyes (20%). The fundus manifestation includes: the retinal vasculitis; dense, full-thickness, yellow-white lesions along vascular distribution, and retinal hemorrhage on the surface; granular with irregular border in the 12 eyes, featured as “cheese and ketchup retinitis”. The vitreous were clear or opaque. Late stage represented grayish atrophic retina, vessel-sclerotic and attenuated, retinal pigment epithelium (RPE) atrophy and prominent choroid vasculature, and optic nerve atrophy in the 2 eyes. Retina detached in the 1 eye. CD4+T-lymphocyte counts between 0~36/mm3, average 15.0±12.9/mm3. Visual acuity had improved in the 4 eyes after intravitreal ganciclovir injection. Fundus lesions disappeared observably and hemorrhage were absorbed.  Conclusions CMV retinitis is the most common and severe intraocular complication in patients with AIDS. Characteristics of CMV retinitis are the progressive necrotizing retinitis with hemorrhage and retinal vasculitis. The vitreous show clear or light opacity. The serum (human immunodeficiency virus, HIV) antibody should be screened for those patients whose fundus showed yellow-white retinal lesions, hemorrhage and retinal vasculitis of underfined cause. Ophthalmological examination should be routinized if positive serological test for HIV.

【Key words】  Cytomegalovirus retinitis;  Acquired immunodeficiency syndrome

    巨细胞病毒性 (cytomegalovirus, CMV) 视网膜炎是获得性免疫缺陷综合征(acquired immunodeficiency syndrome, AIDS)患者最常见的晚期眼部机会性感染[1]。常发生于CD4+T淋巴细胞计数低于50/mm3的患者，可引起进行性全层视网膜坏死，视神经萎缩，最终导致视力丧失。在高效抗反转录酶病毒治疗(highly active antiretroviral therapy, HAART)（鸡尾酒疗法）应用之前，约20～30％人类免疫缺陷病毒(human immunodeficiency virus, HIV) 感染者合并CMV视网膜炎[2]。近年来，由于HAART的应用，CMV视网膜炎的发病率下降了55～95％[3]。尽管CMV视网膜炎发病率已经下降，但由于AIDS患者的生存时间延长，CMV视网膜炎患者的绝对数增多，因此对CMV视网膜炎的正确诊断，眼部和全身的及时、合理治疗是非常重要的[4]。

    对象和方法

    2001～2004年于北京协和医院眼科就诊的73例HIV/AIDS患者中，已确诊8例AIDS[5]患者的15只眼合并CMV视网膜炎。男性3人，女性5人。年龄25～51岁，平均35岁。双眼患病者7人，单眼患病者1人。随诊2~34个月，平均16个月。其中2例患者眼部为首发病变，他/她们因双眼视力下降初诊在我科门诊，经过详细眼部检查诊断为“双眼CMV视网膜炎”，继之行血清HIV抗体检测，结果阳性而转我院感染科确诊为AIDS。

    另外2例患者初诊就医于外地医院。其中1例患者曾被诊断为“视网膜血管炎”，并施行了眼底激光治疗。另外1例患者被诊断为“白塞氏病”，曾全身使用大剂量免疫抑制剂，如：环胞霉素A、环磷酰胺和强的松。

    所有患者在我科就诊时均进行了双眼眼部常规检查：视力，裂隙灯下检查眼前节，散瞳检查眼底，眼底荧光血管造影。其中2例患者因双眼视力急剧下降，分别于局部麻醉下对4只眼施行了“更昔洛韦玻璃体腔注药术”，更昔洛韦1次剂量为400mg。8例患者均在我院感染科进行CD4+T淋巴细胞检测[6]，并接受全身治疗。

[1] [2] [3] 下一页