视神经减压术与药物治疗对颅内静脉血栓性视乳头水肿的效果比较

Comparison of the therapeutic effects of optic nerve sheath fenestration and medication on papilledema due to cerebral venous thrombosis

目的比较视神经减压术(ONSF)和药物治疗对颅内静脉血栓(CVT)性视乳头水肿的效果。方法回顾性纳入2017年1月至2022年7月于北京天坛医院和北京宣武医院因CVT导致高颅压视乳头水肿而接受ONSF的76例患者(107眼)为手术组,纳入接受药物治疗的35例患者(69眼)为药物组。依视乳头水肿Frisén分级,将患者分为轻、中和重度水肿亚组。比较两组患者各亚组治疗前和治疗后1个月视野平均缺损(MD)、Frisén视乳头水肿程度及视乳头平均视网膜神经纤维层(RNFL)厚度的变化。结果手术组76例患者,男26例,女50例,年龄(35.3±11.4)岁;药物组35例患者,男22例,女13例,年龄(35.2±11.0)岁。治疗后1个月与治疗前比较,手术组中度水肿[(-8.4±6.6)比(-11.8±8.6)db,P=0.021]和重度水肿[(-8.1±5.3)比(-11.4±6.9)db,P<0.001]亚组MD值均有改善,药物组轻度水肿亚组MD值改善[(-1.5±5.3)比(-3.4±5.1)db,P<0.001];手术组(P<0.001)和药物组(P=0.010)Frisén视乳头水肿程度均有改善;手术组轻度水肿[(78.5±13.5)比(91.0±17.4)μm,P=0.002]、中度水肿[(126.6±67.6)比(154.8±77.9)μm,P=0.011]和重度水肿[(179.0±70.9)比(230.6±89.7)μm,P=0.001]亚组RNFL厚度均减小,药物组中度水肿亚组RNFL厚度减小[(142.0±29.3)比(158.8±22.7)μm,P=0.020]。结论ONSF能改善CVT性视乳头水肿程度,提高中、重度视乳头水肿患者的视功能。药物治疗对轻度视乳头水肿患者有益。

Objective To compare the therapeutic effects of optic nerve sheath fenestration(ONSF)and medication on papilledema induced by cerebral venous thrombosis(CVT).Methods Patients with papilledema induced by CVT in Beijing Tiantan Hospital and Xuanwu Hospital from January 2017 to July 2022 were retrospectively enrolled and were divided into two groups according to the treatment strategies they underwent,with 76 cases(107 eyes)in ONSF group and 35 cases(69 eyes)in medication group.The degree of papilledema was evaluated by the modified Frisén′s grading(grade 0-1 was defined as mild,grade 2-3 was moderate,and grade 4-5 was severe edema).The mean defect(MD)of visual field,the degree of papilledema,and the mean retinal nerve fiber layer(RNFL)thickness in different subgroups were compared between baseline versus 1 month after ONSF or medication.Results There were 76 cases in ONSF group(26 males and 50 females),and aged(35.3±11.4)years.Meanwhile,there were 35 cases in medication group(22 males and 13 females),and aged(35.2±11.0)years.Compared with baseline,MD were improved in both moderate[(-8.4±6.6)vs(-11.8±8.6)db,P=0.021]and severe[(-8.1±5.3)vs(-11.4±6.9)db,P<0.001]papilledema subgroups after ONSF,while there was an improvement in mild papilledema subgroup[(-1.5±5.3)vs(-3.4±5.1)db,P<0.001]after medication.The papilledema(Frisén′s scores)in both ONSF group(P<0.001)and medication group(P=0.010)was improved.Compared with baseline,the mean RNFL decreased in mild[(78.5±13.5)vs(91.0±17.4)μm,P=0.002],moderate[(126.6±67.6)vs(154.8±77.9)μm,P=0.011]and severe[(179.0±70.9)vs(230.6±89.7)μm,P=0.001]papilledema subgroups after ONSF,while the mean RNFL decreased[(142.0±29.3)vs(158.8±22.7)μm,P=0.020]in moderate papilledema subgroup after medication.Conclusions ONSF might attenuate CVT-mediated papilledema,and improve the visual function in patients with moderate and severe papilledema.Likewise,patients with mild papilledema could also get benefit from medication.