【摘要】 目的：比较玻璃体腔注射曲安奈德和传统方法治疗视网膜静脉阻塞黄斑水肿的疗效。方法：共有21例因视网膜静脉阻塞导致黄斑水肿的患者纳入此项临床研究。接受治疗前所有的患者均进行了全面的眼科检查，并随机分为两组。实验组9例患者进行玻璃体腔注射4mg曲安奈德治疗；对照组12例患者接受传统方法治疗。结果：治疗前，对照组视力（logMAR）为1.20±0.38，而实验组为1.64±0.31。治疗后1mo，对照组的视力改善到0.98±0.54（logMAR），而曲安奈德治疗组改善到0.87±0.61（logMAR）。实验组和对照组之间视力改善有显著差异（P<0.01）。结论：研究结果显示，尽管实验组和对照组的患者视力均有改善，但治疗视网膜静脉阻塞黄斑水肿，玻璃体腔注射曲安奈德比传统方法更有效。
【关键词】 视网膜静脉阻塞 黄斑水肿 玻璃体腔注射 曲安奈德
INTRODUCTION
Retinal vein occlusion occurs when the circulation of retinal vein becomes obstructed by an adjacent blood vessel or thrombosis, causing hemorrhages in the retina[1,2]. Approximately two in 1000 persons aged 40 years or older developed retinal vein occlusion over a fouryear period in population based on study performed in Israel[3]. In persons aged 65 years or older, this increased to five per 1000 individuals. Overall, 90% of patients who develop vein occlusion are over 50 years of age[4].
Despite its relatively common incidence, there are limited effective treatments to improve visual outcomes. Macular edema (ME) is a major cause of vision loss in patients with retinal vein occlusion. The Central Vein Occlusion Study Group showed that grid pattern focal photocoagulation reduced angiographic evidence of macular edema but without any visual benefit[5]. For ME associated with branch retinal vein occlusion (BRVO), grid laser photocoagulation may be an effective treatment, but many patients derive limited benefit from this treatment[6]. Therefore the development of new treatment modalities to treat macular edema caused by these two conditions is an important research goal. Triamcinolone acetonide is a corticosteroid suspension without known retinal toxicity when injected intravitreally and has been shown to reduce breakdown of the inner blood retinal barrier. Also triamcinolone remains in the vitreous cavity at least 3 months and complications are minimal so must be contemplated as a good therapeutic approach[7]. Ip et al [8] described 13 patients and Bashshur et al [9] described 20 patients treated with intravitreal triamcinolone acetonide (IVTA), and encouraging initial results were obtained. Also IVTA has been shown to be safe and effective when used for the treatment of cystoid ME caused by uveitis[10], diabetic maculopathy [11] and post cataract surgery[12].
The purpose of this study was to compare safety and effectiveness of IVTA and conventional treatment for ME due to retinal vein occlusion.
MATERIALS AND METHODS
This study is a randomized casecontrol trial that was performed in Shahid Sadoughi University in 20032004.This study compared the safety and effectiveness of treatment with intravitreal triamcinolone acetonide (IVTA) vs conventional treatment (standard laser therapy) for macular edema (ME) due to retinal vein occlusion. Patients aged 18 years and older with ME due to central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) of between 1 and 18 months duration are eligible for this study. Candidates are screened with a medical history, blood pressure measurement and pregnancy test for women who can become pregnant.
Prior to treatment all patients underwent an ophthalmic examination to assess visual acuity (VA), intraocular pressure (IOP) with Goldmann applanation tonometer and slitlamp and dilated examination (with indirect ophthalmoscope and 3mirror lenses). Fluorescein angiography was performed to evaluate the retinal blood vessels.
Participants were randomly assigned to receive IVTA injection or conventional treatment including anticoagulant therapy and if necessary laser photocoagulation (edema in BRVO or neovascularization in CRVO). After describing the study for patients and obtaining participants consent, 4mg TA (Kenalog) was injected into the vitreous after topical anesthesia (in phakic patients from 4mm distance of limbus and aphakic patients from 3.5mm distance of limbus and with needle number 27). Control group was treated with aspirin and laser treatment was used in chronic ME and neovascularization. Patients with history of allergy to any corticosteroid, positive pregnancy test, agerelated macular degeneration, uveitis or other ocular inflammatory diseases, neovascular glaucoma, IrvineGass syndrome, prior maculaoff rhegmatogenous retinal detachment, substantial cataract, IOP greater than or equal to 25mmHg, open angle glaucoma, pars plana vitrectomy and history of grid laser photocoagulation for macular edema were excluded. All participants were followed after a day, a week and monthly. Also patients underwent similar examinations on followup. Informed consent was obtained from all subjects and the research had the approval of the institutional review board and ethics committee of Yazd University of Medical Sciences and was carried out in accordance with the Declaration of Helsinki.
Statistical Analysis Statistical analysis was performed using Statistical Package for Social Sciences (SPSS version 13.0, Chicago IL).Visual acuity was measured by Snellen Charts at baseline and after treatment and converted to log MAR units to perform ttest statistical analysis.Independent sample ttest was used to compare discrete variables.The level of statistical significance was fixed at P<0.05 with 95% confidence interval.
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