3讨论
黄斑部位的CNV,由于新生血管可以破坏视网膜色素上皮细胞,而且当新生血管发生出血渗出时,可以引起患者中心视力不可逆性的损伤[1]。不同年龄患者发生CNV病因不同。对于CEC的诊断,首先要排除其它可以引起CNV的相关眼部疾病,而且CEC患者发病年龄多在20~40岁。这是一种严重影响患者视力和生活质量的疾病,因为患者的年龄相对年轻,所以对这种疾病的及时有效的治疗就更显得更加重要。评价一种新的治疗方式的有效性和安全性方式就是使用现有的回顾性病例资料与以往文献中所报告的治疗结果相比较。我们询问一些文献报道的PDT对继发于CEC的CNV的治疗结果[3,12]。我们的病例治疗视力结果与文献报道中相似。另一项十分重要的评价指标是PDT的治疗次数,以往的文献报道中提到,在12mo的随访过程中平均PDT的治疗次数是1.8次[7],虽然这个治疗次数已经比PDT治疗黄斑变性和病理性近视的次数低了很多[1315]。但是因为PDT的价格昂贵,这个治疗次数还是有一部分患者不能接受。正是由于出于对经济承受能力的考虑,很多医生尝试使用bevacizumab,一些已经发表的文献证实bevacizumab对于继发于AMD的CNV患者有效[1618]。我们的治疗结果显示,视力提高≥2行者34眼(85%),视力稳定5眼(12.5%),视力下降2行者1眼(2.5%),这个视力结果好于以往的病例报道结果,而且我们的患者整个的治疗过程中只接受一次PDT治疗,最少的接受了一次bevacizumab治疗,最多接受3次bevacizumab治疗。这样的视力的结果是来自于PDT治疗对于新生血管的物理性封闭作用,PDT治疗后利用抗新生血管生成因子bevacizumab的作用,可以减少PDT治疗后内环境中新生血管生长因子的反应性增高,减少PDT治疗后CNV复发的可能。同时,bevacizumab的作用还包括减少CNV病灶的出血渗出,所以,联合治疗后患者的视力效果优于PDT单独治疗的视力效果。PDT还被认为是一种比较安全的治疗CNV的方式,球内注射bevacizumab治疗最严重的不良反应就是球内感染,所以,联合PDT治疗后同样可以减少bevacizumab药物球内注射的次数,减少感染的几率。在我们这组病例中,没有患者出现严重的眼部和/或全身不良反应。所以,我们认为联合治疗是一种安全的治疗方式。基于对我们现有病例的分析,我们认为PDT联合bevacizumab药物对于继发于CEC的CNV是一种安全有效的治疗方式。由于我们的报告是基于以往病例的回顾性分析,所以存在一定的局限性。联合治疗的有效性和安全性仍然需要大样本对照试验的进一步证实。
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