新生血管性青光眼的综合治疗分析

发布时间：2018-02-10 08:56

  本文关键词： 新生血管性青光眼 眼压 虹膜新生血管 雷珠单抗 综合治疗　出处：《郑州大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究背景新生血管性青光眼(neovascular glaucoma,NVG)被认为是一种具有高致盲率的眼部疾患,为难治性青光眼。其主要继发于糖尿病视网膜病变、视网膜中央静脉阻、眼缺血综合征等疾病,同时眼外伤、眼部肿瘤等疾病亦可引起新生血管性青光眼的发生。NVG的发生是由于各种原因导致视网膜血流供应减少,引起视网膜缺血缺氧,导致视网膜产生血管内皮生长因子(Vascular endothelial growth factor,VEGF)产生增加,导致虹膜、房角及小梁网大量新生血管形成,引起小梁网的阻塞和房角的进行性的关闭从而阻止了房水的正常流出通道,使眼压不断升高,进而引起眼部疼痛。同时随着眼压的不断升高,眼部缺血缺氧未得到控制,进而造成视神经的损害,造成视力的损害。然而对于NVG的治疗有很多种方法,主要是通过应用降低眼压的药物和手术治疗为主,但是这两种方法的效果却不明显。随着抗VEGF的药物研发和临床上的使用,为NVG的治疗又提出了新的理念。在手术治疗NVG之前,予以抗VEGF药物的注射,待虹膜和小梁网表面完全消退或大部分消退后再进行手术治疗。由于患者就诊时病情及家庭经济情况的不同,应从多方面考虑,予以一个更加合理的治疗方案。所以根据患者的实际情况选择合理的个体化的综合治疗为治疗NVG的提出了新的理念。目的本研究通过对NVG患者进行的综合治疗来客观评估和探讨个体化综合治疗的效果,并为临床治疗NVG提供一个依据。材料和方法选取2014年10月至2016年1月在郑州大学人民医院(河南省人民医院)就诊并接受治疗的NVG患者67例共70只眼进行回顾性分析,其中男性患者30例32只眼,女性患者37例38只眼,年龄29~76岁,平均年龄(57.9±12.2)岁,其中糖尿病视网膜病变继发NVG的患者32例34只眼,视网膜中央静脉阻塞继发NVG患者29例30眼,其他疾病引起的NVG患者6例6只眼。其中眼压≤21mmHg但有虹膜新生血管即虹膜红变的患者共19例20只眼,眼压21mmHg的患者共48例50只眼。排除既往患有青光眼患者、既往行眼部手术和接受视网膜激光光凝的患者、无视力患者。其中眼压≤21mmHg(虹膜红变)的20只眼接受了单纯的PRP治疗,眼压21mmHg的患者在先完成雷珠单抗0.05ml注射后,根据患者3~7天内虹膜新生血管消退情况、眼压以及眼部屈光间质情况接受了不同的治疗方案:(1)经注药治疗后眼压≤21mmHg的18只眼予以PRP治疗其中10眼因玻璃体积血另外进行了玻璃体手术来改善屈光间质;(2)经注药治疗后眼压21mmHg的19只眼予以复合式小梁切除术+PRP治疗,13只眼予以复合式小梁切除术+玻璃体切割+PRP治疗。对于眼压≤21mmHg的患者记录治疗前和治疗后1周、1个月、3个月、6个月的眼压;对于眼压21mmHg的患者记录注药前和接受个体化综合治疗后1周、1个月、3个月、6个月的眼压;同时记录接受个体化总综合治疗前眼压。应用SPSS 24.0统计学软件进行统计学分析,对于治疗前和治疗后各个时间点的眼压情况应用单因素重复测量方差分析,对注药前与手术前眼压对比进行配对t检验分析,对于治疗前与注药后结果以P0.05为差异具有统计学意义。结果(1)对于眼压≤21mmHg(虹膜红变)的20只眼在随访期间有14只眼在完成PRP治疗后虹膜新生血管完全消退,有6只眼在随访过程中接受玻璃体腔注射雷珠单抗后虹膜新生血管消退。对于眼压21mmHg的50只眼在接受玻璃体腔注射雷珠单抗后有22只眼在3天内虹膜新生血管完全消退,在注药后1周有45只眼虹膜新生血管完全消退,5只眼虹膜新生血管大部分消退,该5只眼于注药后9天完全消退。在接受个体化治疗后有5例患者出现虹膜新生血管复发,在再次接受雷珠单抗注射后消退。(2)眼压≤21mmHg(虹膜红变)的20只眼在末次随访时有7只眼视力有不同程度的提高,11只眼视力保持原状,2眼视力较之前下降。眼压21mmHg的50只眼在末次随访时有20只眼视力有不同程度的提高,21只眼视力维持原状,9只眼视力较之前下降。(3)对于眼压≤21mmHg(虹膜红变)的20只眼激光治疗前眼压、治疗后1周、1个月、3个月、6个月眼压分别为:(18.35±1.04)mmHg;(18.25±1.58)mmHg;(17.80±1.79)mmHg;(17.85±1.53)mmHg;(17.95±1.53)mmHg。与治疗前对差异无统计学意义P0.05。对于眼压21mmHg的50只眼在注药前的眼压为(47.60±6.46)mmHg,接受个体化治疗后1周、1个月、3个月、6个月的眼压分别为:(17.62±5.12)mmHg;(17.40±4.91)mmHg;(17.34±4.20)mmHg;(17.02±4.47)mmHg。进行个体化综合治疗后各个时间点的眼压于注药前相比均具有统计学意义P0.05。(4)所有接受复合式小梁切除术的32只眼中,在末次随访时维持有功能滤泡的有20只眼,12只眼为瘢痕型滤过泡。(5)所有手术患者均未出现视网膜脱离、脉络膜脱离等手术并发症,个体化综合治疗后有3例患者出现浅前房,予以阿托品散瞳加压包扎后3天恢复正常,有6只眼出前房积血,于术后3~7天内消失。结论1.单纯的PRP治疗可以有效的消退虹膜红变患者的虹膜新生血管。2.玻璃体腔注射雷珠单抗联合PRP可以有效的消退虹膜新生血管,降低眼内压。3.复合式小梁切除术联合改善屈光间质手术可以安全有效的治疗NVG。4.根据患者的不同情况选择合理的个体化综合治疗对于NVG的治疗安全、有效,能够安全有效的控制眼内压。
[Abstract]:The research background of neovascular glaucoma (neovascular glaucoma NVG) is considered to be a high rate of blindness eye disease, refractory glaucoma. The main secondary to diabetic retinopathy, retinal vein obstruction, ocular ischemic syndrome and other diseases, and ocular trauma, tumor and other diseases can also cause ocular neovascular glaucoma the occurrence of.NVG occurs due to retinal blood flow to reduce the supply of a variety of reasons, cause retinal ischemia and hypoxia, leading to retinal vascular endothelial growth factor (Vascular endothelial, growth factor, VEGF) have led to increased iris angle and trabecular meshwork abundant neovascularization caused by obstruction of the trabecular meshwork and angle of the closed so as to prevent the normal aqueous outflow channel, so that the pressure rising, causing eye pain. At the same time as the eye pressure increasing, eye Hypoxia ischemia has not been controlled, thereby causing damage to the optic nerve, cause vision damage. However, there are many methods for the treatment of NVG, mainly through the application of reducing drug and surgical treatment of intraocular pressure, but the effect of these two methods is not obvious. With the use of drug development and clinical anti VEGF. For the treatment of NVG and puts forward a new concept. Before surgical treatment of NVG, treated with anti VEGF drugs, the iris and trabecular surface disappeared completely or mostly subsided after surgery. Patients due to illness and family economic situation is different, we should consider many aspects to a more reasonable treatment. So according to the actual situation of patients to choose reasonable individualized comprehensive treatment for the treatment of NVG put forward a new concept. The objective of comprehensive treatment for NVG patients with the view of visitors through the study To evaluate the effect of individualized and comprehensive treatment, and provide a basis for clinical treatment of NVG. Materials and methods from October 2014 to January 2016 in the people's Hospital of Zhengzhou University (Henan Province People's Hospital) patients and NVG patients treated 67 cases of 70 eyes were retrospectively analyzed, including 30 cases of male patients 32 eyes, 37 cases of female patients 38 eyes, age 29~76 years old, average age (57.9 + 12.2) years old, the diabetic retinopathy secondary NVG patients 32 cases 34 eyes, 29 eyes of 30 cases patients with NVG secondary to central retinal vein occlusion and other diseases caused by NVG in 6 cases of 6 eyes. The intraocular pressure is less than 21mmHg but is rubeosis of iris neovascularization a total of 19 patients 20 eyes, intraocular pressure in 21mmHg patients with a total of 48 eyes of 50 cases who suffered from glaucoma patients. Excluded, patients undergoing eye surgery and underwent laser photocoagulation in patients without visual acuity. The intraocular pressure is less than or equal to 21mmHg (rubeosis) 20 eyes received PRP treatment alone, intraocular pressure with 21mmHg prior to complete ranibizumab after 0.05ml injection, according to the patients within 3~7 days of iris neovascularization, intraocular pressure and ocular refractive interstitial received different treatment regimens: (1) to PRP treatment the 10 eyes with vitreous hemorrhage in the vitreous body surgery to improve the refractive interstitial injection for the treatment of 18 eyes after intraocular pressure less than 21mmHg; (2) to be combined trabeculectomy in 19 eyes treated by +PRP injection for the treatment of IOP after 21mmHg, 13 eyes of compound trabeculectomy + vitreous body cutting +PRP = 21mmHg for treatment. The intraocular pressure were recorded before and after treatment for 1 weeks, 1 months, 3 months, 6 months for intraocular pressure; intraocular pressure 21mmHg were recorded before injection and receive individualized comprehensive treatment after 1 weeks, 1 months, 3 months, 6 months Intraocular pressure; records of individual total IOP before treatment at the same time. The application of SPSS 24 statistical software for statistical analysis, for the treatment of intraocular pressure before and after treatment application each time point of the single factor analysis of variance of repeated measurement, of before injection and preoperative intraocular pressure compared with paired t test analysis for before treatment and drug injection results after P0.05 the difference was statistically significant. Results (1) for intraocular pressure less than 21mmHg (rubeosis) 20 eyes have 14 eyes and iris neovascularization disappeared completely in PRP after treatment during the follow-up period, 6 eyes received intravitreal injection of ranibizumab during follow-up after neovascularization of iris for. 50 eyes IOP in 21mmHg received intravitreal ranibizumab injection after 22 eyes in iris neovascularization within 3 days completely disappeared in 1 weeks after injection, 45 eyes with iris neovascularization disappeared completely, 5 鍙�鐪艰櫣鑶滄柊鐢熻。�

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