【摘要】 目的：探讨病理性近视黄斑出血的眼底改变及其光学相干断层扫描特征。方法：对42例43眼病理性近视(PM)黄斑出血患者进行眼底彩色照相、荧光素眼底血管造影(FFA)和光学相干断层扫描(OCT)检查。结果：病理性近视黄斑出血的表现分为两类：新生血管型：24例24眼，其眼底特征表现为出血灶呈类圆形，不超过1PD，周围少见渗出及水肿，部分可见新生血管膜;其FFA特征表现为典型性CNV 17眼(71%)，隐匿性CNV 7眼(29%);其OCT特征表现为21眼(87.5%)CNV呈纺锤形或类圆形团块状，呈强或中等强度反射，自视网膜色素上皮层向上突出，位于视网膜神经上皮层下，3眼(12.5%) CNV呈不规则增强紊乱的反射信号，位于视网膜色素上皮层平面。单纯型：18例19眼;其眼底特征表现为出血灶扁平，大小不等，边界欠整齐，周围无渗出及水肿，其FFA特征表现为出血遮蔽荧光，无CNV性高荧光征象，部分患眼可见漆裂纹样透见荧光;其OCT特征表现为色素上皮层下隆起低反射区，脉络膜毛细血管层光带连续。结论：病理性近视新生血管型黄斑出血绝大部分由典型性CNV引起，OCT的典型图像为色素上皮层局限的纺锤状或类圆形的强反射光团，边界较清，视网膜向上隆起，下方可有脉络膜遮蔽;单纯型黄斑出血表现为局限性色素上皮层出血性脱离，OCT检查有利于明确病理性近视黄斑出血的病变性质和病因，并有助于判断预后和指导治疗。
【关键词】 病理性近视;黄斑出血;脉络膜新生血管;光学相干断层扫描
Optical coherence tomography and fundus fluorescein angiography for macular hemorrhage in pathological myopia
Jie Zhao1, XiaoDong Sun2, Hao Lu1, Liang Yan1, Jie Qin1
1Department of Ophthalmology, Baoshan District Central Hospital, Shanghai 201900, China; 2Department of Ophthalmology, the First Peoples Hospital, Medical College of Shanghai Jiaotong University, Shanghai 200080, China
Correspondence to: XiaoDong Sun. Department of Ophthalmology, the First Peoples Hospital, Medical College of Shanghai Jiaotong University, Shanghai 200080, China. [email protected]
Received:20100512 Accepted:20100708
Abstract
AIM: To evaluate the characterization of macular hemorrhage in pathological myopia (PM) with optical coherence tomography (OCT) and fundus fluorescein angiography (FFA).
METHODS: A series of retrospective cases study was designed. OCT, FFA and color photography were performed on 42 patients 43 eyes of PM with macular hemorrhages.
RESULTS: The causes and symptoms of PM with macular hemorrhage could be divided into two forms: new veins: macular hemorrhage with choroidal neovascularization (CNV) of 24 patients 24 eyes. The fundus characteristics were macular hemorrhage demonstrated oval, less than 1 disk diameter (PD), with rare edema and exudation around. And new membrana vasculosa can be seen partially. The FFA characterisitics were classic CNV of 17 eyes (71%) and occult CNV of 7 eyes (29%). The characteristics of OCT were 21 eyes (87.5%), spindle shape or circular conglomerate, strong or medium reflection, sticking out upwards from retinal pigment epithelial layers, under the epithelial layers of retinal neuroepithelial; 3 eyes (12.5%) CNV were irregular reflection signal which may aggregate disorder, and located on the level of retinal pigment epithelial layers. Simplex: macular hemorrhage without CNV of 18 patients 19 eyes. The fundus characteristics were flat hemorrhagic focus with different sizes and lessorderly boundary, without any exudation or edemas around. The FFA characterisitics were fluorescence blocked by hemorrhage, without CNV high fluorescence phenomenon. Lacquer cracks sometimes appeared at the sites of macular hemorrhage or around the hemorrhage. The characteristics of OCT were the protruded low reflection area under the retinal pigment epithelial. Choriocapillary layer with consistent photonic band.
CONCLUSION: Most of macular hemorrhage in pathological myopia with new veins is caused by typical CNV. Typical figures of OCT are fusiform shape in pigment epithelium layers or quasicircular strong reflection mass, with clear boundary. Retinal protruded upwards, and choroids under it can be a shield. Simplex macular hemorrhage demonstrates as limited retinal pigment epithelial hemorrhagic detachment. OCT examinations were favorable for identifying the characteristics and reasons of macular hemorrhage in pathological myopia, and were helpful for diagnosis, prevention, guide and treatment.
KEYWORDS: pathological myopia; macular hemorrhage; choroidal neovascularization; optical coherence tomography
Zhao J, Sun XD, Lu H, et al. Optical coherence tomography and fundus fluorescein angiography for macular hemorrhage in pathological myopia. Int J Ophthalmol(Guoji Yanke Zazhi) 2010;10(9):17651767
病理性近视(pathological myopia, PM)常伴发眼后极部的变形改变，可伴有多种并发症，由它引起的黄斑病变已逐渐成为低视力或盲目的主要致病原因之一[1]。PM黄斑病变包括黄斑出血、萎缩、漆裂纹及Fuchs斑等改变，其中黄斑出血尤使人关注[2,3]。PM黄斑出血临床上可分为新生血管(choroidal neovascularization, CNV)型和单纯型两种[4,5]，这两种不同类型黄斑出血形成原因、眼底表现及视力预后有很大的不同[6]。如何更好的鉴别这两种黄斑出血，对于疾病诊断和指导治疗具有重要的临床意义。我们的研究对42例43眼PM黄斑出血患者行眼底彩色照相、荧光素眼底血管造影(fundus fluorescein angiography, FFA)及光学相干断层扫描(optical coherence tomography, OCT)检查，探讨这3种检查方法对于PM黄斑出血的诊断价值。
1对象和方法
1.1对象
选取20050616/20070918就诊于上海市宝山区中心医院眼科的PM黄斑出血患者共42例43眼，其中男18例，女24例;年龄18～76(平均43.5岁);屈光度6.0～24.0(平均11.9)D，矫正视力为0.01～0.9。所有患者行眼底彩色照相、FFA和OCT检查，排除合并其他眼部及全身性出血性疾病患者。
1.2方法
所有患者均检查裸眼视力及经散瞳验光检查矫正视力。ZeissFF 450型眼底照相机行眼底照相。采用200g/L荧光素钠3mL(广西梧州制药厂)及 Zeiss FF 450眼底照相机,按常规方法行FFA。Stratus 3000 OCT行覆盖黄斑出血病灶的多条平行线扫描和以黄斑出血病灶为中心的放射状扫描。
2结果
(1)新生血管型黄斑出血：24例24眼。眼底彩色照相显示：黄斑区有小片状深层出血，出血灶呈类圆形，大小一般<1PD，周围很少伴有渗出、水肿，部分病例可在出血区域内或出血附近见到一灰黑色、略隆起、表面圆钝、边界清晰的CNV膜(图1)。FFA显示：典型性CNV 17眼(71%)，表现为造影动脉期可见绒团状、车辐状或斑片状边界清楚的强荧光，周围常绕以弱荧光环，随时间延长染料渗漏，后期染料积存(图2);隐匿性CNV 7眼(29%)，表现为造影早期斑片状遮蔽荧光，其内或边缘可见边界欠清的CNV性强荧光，随时间延长染料渗漏，后期染料积存(图3)。OCT显示：21眼(87.5%)CNV呈纺锤形或类圆形团块状，呈强或中等强度反射，自视网膜色素上皮层向上突出，位于视网膜神经上皮层下(图4);3眼(12.5%)CNV呈不规则增强紊乱的反射信号，位于视网膜色素上皮层平面(图5)。(2)单纯型黄斑出血：18例19眼。眼底彩色照相显示：黄斑区有一红色扁平出血区，大小不等，边界欠整齐，出血灶周围无渗出及水肿(图6)。FFA显示：黄斑区可见出血遮蔽荧光，造影期间均未见CNV性高荧光征象(图7)。其中9眼在出血低荧光区内或其边缘处可见一条或数条长短不一的漆裂纹样透见荧光;另10眼在出血低荧光区内或其边缘未见漆裂纹形成。OCT显示：色素上皮层下隆起的拱形低反射区，隐约可见脉络膜毛细血管层光带平滑连续(图8)。图1 新生血管型黄斑出血。图2 典型性CNV的FFA图像，造影早期黄斑部出现荧光渗漏。图3 隐匿性CNV。显示早期透见荧光及遮蔽荧光，中晚期少量荧光渗漏。图4 CNV呈中等强度反射的类圆形团块，自视网膜色素上皮层平面向上生长。图5 CNV沿视网膜色素上皮层平面生长。图6 单纯型黄斑出血。图7 单纯黄斑出血的FFA像。黄斑部造影全程无荧光渗漏。图8 色素上皮层下出血，脉络膜毛细血管层光带连续。
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