【摘要】 评价经瞳孔温热疗法（TTT）治疗年龄相关性黄斑变性（AMD）所致黄斑中心凹下脉络膜新生血管（CNV）的长期疗效。
方法：AMD所致黄斑中心凹下脉络膜新生血管14例14眼。平均年龄67.1岁。记录详尽的眼科检查结果，拍摄彩色眼底相，并行黄斑部光学相干断层成像（OCT）检查。在初诊及随后的复诊中行眼底荧光素血管造影和吲哚青绿血管造影。TTT的治疗参数为：时间1min，光斑大小2～3mm，激光能量650～800mW。随诊时间5～ 64mo,平均28.6mo。
结果：在14眼中，典型性CNV有10眼，典型为主性有2眼，1眼为少量典型性，1型隐匿性CNV有1眼。共4例患者出现治疗后出血，均在短期内吸收。有1眼在治疗后立刻出现了黄斑无灌注区。多数患眼在随诊中可见渗出逐渐减少。在平均28.6mo的随诊中，14只患眼，有5眼视力提高，8眼保持稳定，1眼视力下降。
结论：经瞳孔温热疗法在AMD患者中能封闭黄斑中心凹下的CNV，促进网膜下积液的迅速吸收，从而稳定患者的视力。它可以作为一种治疗典型和典型为主性黄斑中心凹下脉络膜新生血管的激光治疗手段。
【关键词】 经瞳孔温热疗法 脉络膜新生血管
INTRODUCTION
Choroidal neovascularization (CNV) is the major cause of severe visual loss in agerelated macular degeneration (AMD). Laser photocoagulation treatment can reduce the incidence of visual loss in cases of extrafoveal and juxtafoveal CNV[1,2]. The Macular Photocoagulation Study Group showed that most patients with juxtafoveal CNV experienced recurrence and patients with subfoveal membranes experienced rapid visual loss following treatment [3,4]. These findings led the investigators to develop new treatments for subfoveal CNV.
Transpupillary thermotherapy (TTT) has emerged from tumor treatment and has recently been adopted for CNV in AMD[5]. Reichel et al[6], first reported the use of TTT for the treatment of occult subfoveal choroidal neovascularization secondary to agerelated macular degeneration. In their pilot study, Reichel and colleagues found that vision improved in 19% of patients and stabilized in 56%, with a decrease in exudation in 94%. Optical coherence tomography demonstrated vascular membrane resolution with a restoration of the macular anatomy. Additional studies have shown similar rates of success in the treatment of occult CNV[79].Favorable results of TTT were also achieved in a small series of predominantly classic CNV[10].
Here we report 28.6month results of a series of patients with subfoveal CNV secondary to AMD treated with TTT.
MATERIALS AND METHODS
We conducted a retrospective review of patients with classic or predominantly classic subfoveal CNV treated with transpupillary thermotherapy. All patients had pretreatment Snellen visual acuity, slitlamp microscopy, funduscopy, color fundus photography, fluorescein angiography (FA) and optical coherence tomography (OCT) of the macular area. Indocyanine green angiography (ICGA) was performed in selected cases.
Treatment was delivered using an infrared diode laser at a wavelength of 810nm equipped with a modified slitlamp adapter with an adjustable beam width (Iris Medical Instruments, Mountain View, CA). After FA was performed the lesion size was measured to determine the appropriate laser spot size setting. For a 3mm spot size, a maximum of 800mW (range 650800mW) was delivered to the retina for a total of 60 seconds with continuous observation through the slitlamp. A threemirror Goldmann lens was used. For smaller spot sizes, the power was decreased proportionally. If the lesion size was greater than 3mm, overlapping treatments were applied. The endpoint for treatment was an area of no visible color change throughout the course of treatment. If retinal whitening was observed during treatment, the power was adjusted by a decrease of 10% and the treatment was restarted.
Retreatment was instituted when fluorescein leakage had not regressed or had increased after the first TTT concomitantly with a significant decline of visual acuity.
RESULTS
Fourteen eyes of 14 AMD patients were included in the study. There were 7 men and 7 women, with a mean age of 67.1 years (range 5278 years). All patients had symptoms, such as metamorphopsia or significant visual acuity loss due to subfoveal choroidal neovascularization. Ten patients had classic, 2 had predominantly classic, one had minimally classic, one had occult type 1 (fibrovascular pigment epithelial detachment) CNV. The mean followup period was 28.6 months (range 564 months).
Ten eyes (72%) received one application of TTT, 3 eyes (21%) two applications and one eye (7%) three applications. Retreatment was needed in 2/14 eyes (14%) at 2 months, in 1/14 eye (7%) at 7 months, in 1/14 eye (7%) at 9 months. The mean interval before retreatment with TTT was five months and the mean number of treatments in fourteen eyes was 1.4.
Four eyes (28%) were noted to have posttreatment hemorrhage which was absorbed in a short time. One eye (7%) suffered from a macular nonperfusion with an acute decline in vision after TTT (Figure 1). At the end of a 49month followup, visual acuity was measured by counting fingers at two meters.
At the 28.6month followup, visual acuity had improved in five eyes (36%) and deteriorated in 1 eye (7%). Thus, 13 of 14 eyes (93%) remained stable or improved in vision. Deterioration of visual acuity was due to postoperative macular nonperfusion in one eye.
With OCT, the fundi were scanned on the horizontal and vertical planes through choroidal neovascularization. Subfoveal CNV was identified as a highly or moderately reflective mass that protruded through the retinal pigment epithelium (RPE). In one case of fibrovascular pigment epithelial detachment, OCT showed an elevation of the RPE above a backscattering area corresponding to fibrovascular proliferation. CNV was usually accompanied by subretinal fluid, retinal edema, intraretinal cysts that appeared as nonhomogenous hyporeflective areas.
One month after TTT and during the followup, OCT showed decreased subretinal and intraretinal fluid and diminished retinal elevation in 93% of the eyes. Late staining of subretinal fibrosis was observed in all cases on fluorescein angiography (Figure 2).
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